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Assiniboine Regional Health Authority Community Health Assessment 2009-2010 AssiniboineRegionalHealthAuthority CommunityHealthAssessment2009/2010 March2010 AssiniboineRegionalHealthAuthority PlanningandEvaluation JodyAllan ColinWilliams AmyRogasky StacyOliver Acknowledgements The members of Community Health Assessment Team wish to express our thanks to everyone who participated in the CHA process. Community members, regional staff, and partner organizations gave of their time to provide us with information and opinions. We could not have completed the CHA without the partners who provided us with the data and the collaborative force of the community health assessment Network. The Community Health Assessment team was coordinated by Jody Allan, who is extremely grateful for the dedicated efforts of the following people: Colin Williams, Amy Rogasky, Stacy Oliver, and Bonnie Mckay. The CHA Team also wishes to thank the Board, Executive Management Committee, the Provider Advisory Council, and the Assiniboine Health Advisory Council for their guidance and support. Ifyouwouldlikemoreinformationaboutthecommunityhealthassessment,please email:[email protected]: CorporateOffice 1921stAve.West Box579Souris R0K2C0 Manitoba Tel:2044835000 RegionalOffice 344ElmStreet Box310,ShoalLake R0J1Z0 Manitoba Tel:2047594500 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 TableofContents ExecutiveSummary....................................................................................... XIII Introduction ....................................................................................................... 1 WhatistheCHA? .......................................................................................................... 1 Methods .......................................................................................................................2 DataPresentationandInterpretation ........................................................................3 Limitations....................................................................................................................5 Chapter1:PopulationDemographics..............................................................7 Population,StructureandChange ............................................................................. 9 PopulationPyramids .................................................................................................. 12 PopulationProjections.............................................................................................. 14 DependencyRatio ..................................................................................................... 15 ChapterHighlights ..................................................................................................... 17 Chapter2:SocialandEconomicDeterminantsofHealth ............................ 19 Culture ........................................................................................................................20 AboriginalPopulation ................................................................................................20 FirstNationPeople..................................................................................................... 22 MétisPeople.............................................................................................................. 27 HutteriteandOldOrderMennonitePeople .............................................................28 Internal/ExternalMigration .......................................................................................29 Immigrants .................................................................................................................30 LanguagesSpokenintheHome................................................................................ 31 Urban/RuralPopulation ...........................................................................................32 CommunityDevelopment..........................................................................................33 Education....................................................................................................................33 Income ....................................................................................................................... 40 Employment ...............................................................................................................45 PhysicalEnvironment.................................................................................................47 HousingAffordability................................................................................................ 48 Transportation .......................................................................................................... 49 SocialSupports...........................................................................................................50 MaritalStatus ............................................................................................................. 51 LoneParentFamilies..................................................................................................52 SocialEnvironments...................................................................................................52 PersonalHealthPracticesandCopingSkills .............................................................53 ChapterHighlights .....................................................................................................54 Chapter3:LifestyleorBehaviouralRiskFactors ..........................................55 BodyMassIndex ........................................................................................................55 HealthyEating ............................................................................................................58 FruitandVegetableConsumption.............................................................................59 FoodSecurity............................................................................................................. 60 PhysicalActivity.......................................................................................................... 61 Smoking ......................................................................................................................65 AlcoholUse................................................................................................................ 69 IllegalDrugUse .......................................................................................................... 72 PG:I PG:IITABLEOFCONTENTS RiskFactorSurveillance ............................................................................................. 72 SelfRatedHealth .......................................................................................................73 FunctionalPhysicalHealth.........................................................................................74 ChronicDiseasePreventionInitiative(CDPI) ...........................................................75 ChapterHighlights .....................................................................................................77 Chapter4:BurdenofIllness ...........................................................................79 Cardiovascular ............................................................................................................79 Hypertension .................................................................................................79 IschemicHeartDiseasePrevalence..............................................................82 AcuteMyocardialInfarction(AMI)HeartAttack.........................................83 AcuteCoronarySyndrome(ACS)CareMap ............................................... 86 CardiacCatheterization................................................................................ 86 CardiacRevascularizationInterventions......................................................87 PercutaneousCoronaryIntervention(PCI)(Angioplasty) ......................... 88 CoronaryArteryBypassSurgery(CABG) .................................................... 89 Strokes(CVA)IncidenceRates .................................................................... 90 StrokeStrategy..............................................................................................92 Diabetes......................................................................................................................93 DiabetesPrevalenceandMortality ..............................................................95 DiabetesCareEyeExams..............................................................................95 DiabetesRelatedLowerLimbAmputations ............................................... 96 RegionalDiabetesProgram/RiskFactorComplicationAssessment..........97 RespiratoryDiseases................................................................................................. 99 TotalRespiratoryMorbidity(TRM) ............................................................. 99 Asthma..........................................................................................................101 RANARespiratoryClinics/HomeOxygen ................................................. 102 OtherChronicConditions ........................................................................................ 104 Arthritis ........................................................................................................ 104 Osteoporosis ............................................................................................... 105 Cancer ....................................................................................................................... 107 CancerIncidence .........................................................................................108 RadiationTreatmentUtilization ...................................................................111 CancerSurvivalRate..................................................................................... 112 CancerMortality........................................................................................... 112 BreastCancerScreening .............................................................................. 113 CervicalCancerScreening............................................................................114 ColorectalCancerScreening........................................................................116 Mortality .................................................................................................................... 117 TotalMortalityRate(TMR)......................................................................... 117 CausesofDeath............................................................................................ 117 UnintentionalInjuryDeaths........................................................................ 120 PrematureMortalityRate(PMR) ................................................................ 121 LifeExpectancy ........................................................................................... 124 PotentialYearsofLifeLost......................................................................... 124 ChapterHighlights....................................................................................... 128 Chapter5:PrimaryCare ................................................................................ 129 PrimaryCareProgram.............................................................................................. 129 PhysicianUse............................................................................................................. 131 AmbulatoryVisitRates............................................................................................. 134 AmbulatoryConsultationRates .............................................................................. 136 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 Continuityofcare..................................................................................................... 137 AmbulatoryVisitRatetoSpecialists ....................................................................... 138 MBTelehealth ...........................................................................................................141 HealthLinksInfoSanté ............................................................................................ 142 ChapterHighlights ................................................................................................... 144 Chapter6:PreHospitalandHospitalBasedCare....................................... 145 EmergencyMedicalServices(EMS) ....................................................................... 145 HospitalBasedCare ................................................................................................. 148 HospitalSeparations ................................................................................................. 151 HospitalDaysUsed .................................................................................................. 157 AmbulatoryCareSensitive(ACS)Conditions.........................................................161 InjuryHospitalization ............................................................................................... 162 SurgicalProgram...................................................................................................... 163 TonsillectomyandAdenoidectomy......................................................................... 164 CataractSurgery....................................................................................................... 165 Hysterectomy ........................................................................................................... 165 ObstetricalServices ................................................................................................. 167 RiversRehabUnit.....................................................................................................169 HipandKneeSurgery .............................................................................................. 170 Physiotherapy/Occupationaltherapy ..................................................................... 170 RenalCareandDialysis .............................................................................................172 SpiritualHealth..........................................................................................................172 HealthcareAssociatedInfections............................................................................ 173 AcuteCareFacilityFalls............................................................................................ 174 MedicationVarianceIncidents ................................................................................ 175 ChapterHighlights ................................................................................................... 176 Chapter7:PublicHealth.................................................................................177 PregnancyandChildBirth.........................................................................................177 PrenatalEducation....................................................................................................177 TeenPregnancy........................................................................................................ 178 BirthRate..................................................................................................................180 BirthWeight ..............................................................................................................181 SizeforGestationalAge........................................................................................... 182 PretermBirths .......................................................................................................... 183 TeenBirthRates....................................................................................................... 184 PostpartumProgram ............................................................................................... 185 WellBaby/ChildHealthClinics ................................................................................. 185 BreastfeedingInitiation ........................................................................................... 185 StillsBirths ................................................................................................................186 InfantMortality ........................................................................................................ 187 ChildMortality ..........................................................................................................188 InjuryMortality.........................................................................................................189 FamiliesFirstProgram .............................................................................................190 ParentChildCoalitions .............................................................................................198 DevelopmentalScreening .......................................................................................198 Children’sTherapyInitiative ....................................................................................198 UnifiedReferralIntakeSystem ...............................................................................199 ChildhoodImmunization ......................................................................................... 201 AdultImmunization ................................................................................................ 206 TravelHealth ........................................................................................................... 208 PG:III PG:IVTABLEOFCONTENTS CommunicableDiseases ......................................................................................... 209 SexuallyTransmittedInfections............................................................................... 211 ChapterHighlights ....................................................................................................212 Chapter8:MentalHealth...............................................................................213 ChildandAdolescentServices................................................................................. 214 AdultServices........................................................................................................... 215 MentalHealthServicesfortheElderly.................................................................... 216 ProctorServices ........................................................................................................217 WestmanCrisisUnit ..................................................................................................217 MentalHealthPromotion ........................................................................................ 218 GeneralMentalHealth............................................................................................. 219 Selfperceivedstress,lifeandwork..........................................................................221 MentalIllnessTreatmentprevalence...................................................................... 222 CumulativeDisorders .................................................................................. 225 AnxietyDisorders ........................................................................................226 Dementia ..................................................................................................... 227 Depression...................................................................................................228 PersonalityDisorders ..................................................................................229 Schizophrenia ..............................................................................................230 SubstanceAbuse ..........................................................................................231 HealthCareUtilization ............................................................................................. 233 AllcauseAcutecarehospitalSeparationRates......................................... 233 PhysicianVisits.............................................................................................236 AntidepressantPrescriptionuse ................................................................ 237 PrescriptionUseinchildren/Adolescents ...............................................................239 SuicideRates ............................................................................................................242 5yearmortalitywithandwithoutCumulativeMentalIllness ...............................243 ChapterHighlights ...................................................................................................244 Chapter9:HomeBasedandLongTermCare .............................................245 HomeCare ................................................................................................................245 NewhomeCareCases .............................................................................................246 OpenHomeCareCases............................................................................................247 HomeCareClosingRate ..........................................................................................248 AverageLengthofHomeCareCases......................................................................249 BenzodiazepinePrescribinginCommunityDwellingSeniors................................249 SupportServicetoSeniors ......................................................................................250 CongregateMealProgram ...................................................................................... 251 MealsonWheels ...................................................................................................... 251 SupportiveHousing ................................................................................................. 251 SupportstoSeniorsinGroupLiving(SSGL) ........................................................... 252 RespiteCare ............................................................................................................. 252 AdultDayProgram................................................................................................... 253 LongTermCarePersonalCareHomes................................................................... 253 LevelofCareonAdmission......................................................................... 255 PCHWaitingTimes ...................................................................................... 257 MedianLengthofStay................................................................................258 QualityofCare..........................................................................................................258 HealthcareAssociatedInfections...............................................................258 BenzodiazepinePrescribing.......................................................................259 IncidentsofResidentsAbusive/AggressiveBehaviour ............................ 260 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 ResidentFalls.............................................................................................. 260 MedicationVarianceIncidents ................................................................... 261 PalliativeCare ...........................................................................................................262 ChapterHighlights ...................................................................................................263 Chapter10:HealthAuthorityCharacteristics..............................................265 RHAExpenditure......................................................................................................265 Communications ..................................................................................................... 266 Leadership ................................................................................................................267 SystemCapacity .......................................................................................................267 ClientSatisfaction ................................................................................................... 268 HumanResources ................................................................................................... 269 StaffOrientation ......................................................................................................270 OccupationalHealthandSafety...............................................................................271 StaffFluImmunizations ............................................................................................271 Worklife .................................................................................................................... 272 StaffEducation......................................................................................................... 272 Volunteers ................................................................................................................ 273 PatientSafety ........................................................................................................... 273 ClientCentreServices .............................................................................................. 273 ChapterHighlights ................................................................................................... 275 ReferenceList ................................................................................................ 277 Appendices.....................................................................................................279 Appendix1ARHAPopulationJune1st2008 ........................................................... 280 Appendix2ARHAYouthHealthSurvey..................................................................287 Appendix3CommunityEngagementMeetings..................................................... 291 Appendix4ARHAStaffSurvey................................................................................293 Appendix5CHAIndicatorList.................................................................................294 PG:V PG:VILISTOFFIGURESANDTABLES ListofFigureandTables Chapter1:Population Figure1.1ARHAGeographicBoundaries ..................................................................................7 Figure1.2ARHAPopulationPercentagebyAgeandGenderJune12008............................ 10 Figure1.3ARHAPercentagePopulationChangebyAgeand GenderJune12003June12008 ............................................................................11 Figure1.4AgeProfileoftheARHAandManitoba,2008....................................................... 12 Figure1.5AgeProfileoftheARHA,2003and2008 ............................................................... 13 Figure1.6ARHAPopulationProjectionsbyAgeGroup20062036 ...................................... 14 Figure1.7ARHADependencyRatiosActualandProjected20062036 ................................. 16 Table1.1TownsandMunicipalitiesoftheARHA..................................................................... 8 Table1.2ARHAPopulationJune2003,2008........................................................................... 9 Table1.3ARHAandManitobaPopulationStructure2006Actualand2036Projected ....... 15 Chapter2:SocialandEconomicDeterminantsofHealth Figure2.1DeterminantsofHealth .......................................................................................... 19 Figure2.2AboriginalPopulation19962006........................................................................... 21 Figure2.3FirstNationsRegionalHealthSurveyDeterminantsofHealth ............................24 Figure2.4Residentswithlessthanahighschooleducationat2006Census(Aged15+) ..34 Figure2.5HighestLevelofEducationbyGender2006(Aged15+) ......................................35 Figure2.6Grade3SchoolStudentswithNoSchoolChangesin4Years1997/982000/01 and2002/032005/06(SexAdjusted) ................................................................... 40 Figure2.7MedianIndividualIncome2001and2006Censuses............................................ 41 Figure2.8MedianHouseholdIncome2001and2006Censuses..........................................43 Figure2.9Unemploymentrate(MaleandFemale)2006Census........................................ 46 Figure2.10PercentageofLoneParentFamilies2006Census ..............................................52 Table2.1Internal/ExternalMigration1996,2001and2006Censuses...................................29 Table2.25YearInternalMigrantMobility1996,2001and2006Censuses .......................... 31 Table2.3LanguagesSpokenIntheHome1996,2001and2006Censuses .......................... 31 Table2.4Urban/RuralPopulationSplit1996and2001Censuses..........................................32 Table2.5HighestEducationLevelsat2006Censusbyagegroup .......................................34 Table2.6AverageEDIscores2005/20062006/2007 .............................................................36 Table2.7Percentofchildrenwhowere‘veryready’forschool2005/20062006/2007 ......37 Table2.8Percentofchildrenwhowere‘notready’forschool2005/20062006/2007 .......38 Table2.9GeneralinformationonARHAkindergartenchildren............................................38 Table2.10MedianIndividualIncome2001and2006Censuses(DistrictandRHA) .............42 Table2.11MedianHouseholdIncome2001and2006Censuses(DistrictandRHA) ........... 44 Table2.12LowIncomePrevalenceat2006Census(DistrictandRHA) ............................... 44 Table2.13YouthUnemploymentRate(1524)2001and 2006Censuses(DistrictandRHA)..........................................................................47 Table2.14HousingAffordabilitybyDistrictandRHA2001and2006Censuses.................. 48 Table2.15MaritalStatusesat2006Census............................................................................ 51 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 Chapter3:LifestyleorBehaviouralRiskFactors Figure3.1BodyMassIndex(BMI)Aged18+(OverweightandObese– AgeandSexAdjustedCCHS20012005) .....................................................................56 Figure3.2BodyMassIndex(BMI)Aged1219(OverweightandObese– SexAdjustedCCHS20012005) ...............................................................................57 Figure3.3DailyFruitandVegetableConsumptionAges12+ (AgeandSexAdjustedCCHS20012004)5orMoreServingsperDay .............59 Figure3.4DailyFruitandVegetableConsumptionAges1219 (SexAdjustedCCHS20012004)5orMoreServingsperDay........................... 60 Figure3.5TotalPhysicalActivityLevelsAge1575(Work,LeisureandTravel) (AgeandSexAdjustedCCHS20012005) ............................................................62 Figure3.6PhysicalActivityLevelsAge1219(SexAdjustedCCHS20012005) .....................63 Figure3.7SmokingRatesAge12+(AgeandSexAdjustedCCHS20012005).......................65 Figure3.8AdolescentSmokingRatesAge1219(Smokedlessthan 100cigarettesintheirlifetime)(SexAdjustedCCHS20012005)......................... 66 Figure3.9SecondHandSmokeExposureAge12+ (AgeandSexAdjustedCCHS20012005) ..............................................................67 Figure3.10SelfReportedHeavyDrinkingAge12+ (AgeandSexAdjustedCCHS20012005) ............................................................. 69 Figure3.11YoungerAdolescentsAged1215WhoDidNotConsumeAlcohol (SexAdjustedCCHS20012005) ...........................................................................70 Figure3.12OlderAdolescentsAged1619WhoDidConsumeAlcohol (SexAdjustedCCHS20012005) ........................................................................... 71 Figure3.13SelfRatedHealthAged12+ (AgeandSexAdjustedCCHS20012005) ...........................................................74 Table3.1SelfRatedHealthAged12+RHAandDistrict (AgeandSexAdjustedCCHS20012005)................................................................73 Chapter4:BurdenofIllness Figure4.1HypertensionTreatmentPrevalence(Aged19+) 2000/01and2005/06(AgeandSexAdjusted) ..................................................... 80 Figure4.2IschemicHeartDisease(IHD)Prevalence(Aged19+)1996/972000/01 and2001/022005/06(AgeandSexAdjusted) ......................................................82 Figure4.3HeartAttack(AMI)Rates(Aged40+)per1000residents 1996/972000/01and2001/022005/06(AgeandSexAdjusted) ........................ 84 Figure4.4CardiacCatheterizationRates(Aged40+)per1000residents 1998/992000/01and2003/042005/06(AgeandSexAdjusted) .......................87 Figure4.5PercutaneousCoronaryInterventions(PCI)(Aged40+)per1000 residents1996/972000/01and2001/022005/06(AgeandSexAdjusted) ........ 88 Figure4.6CoronaryArteryBypassSurgery(CABG)(Aged40+)per1000residents 1996/972000/01and2001/022005/06(AgeandSexAdjusted) ........................ 89 Figure4.7StrokeIncidenceRates(Aged40+)per1000residents 1996/972000/01and2001/022005/06(AgeandSexAdjusted) ......................... 91 Figure4.8DiabetesTreatmentPrevalenceAged19+ (AgeandSexAdjusted–1998/992000/01and2003/042005/06)..................... 94 Figure4.9DiabetesCareEyeExaminationsAged19+2000/01and2005/06....................... 96 Figure4.10TotalRespiratoryMorbidityTreatmentPrevalence 2000/01and2005/06(AgeandSexAdjusted).................................................100 Figure4.11ArthritisPrevalence(aged19+)1999/002000/01 PG:VII PG:VIIILISTOFFIGURESANDTABLES and2004/052005/06(AgeandSexAdjusted)................................................... 104 Figure4.12OsteoporosisPrevalence(Aged50+)1998/992000/01 and2003/042005/06(AgeandSexAdjusted).................................................106 Figure4.13MaleCancerIncidenceper100,00020002002 and20032005(AgeAdjusted).........................................................................109 Figure4.14FemaleCancerIncidenceper100,00020002002 and20032005(AgeAdjusted)..........................................................................109 Figure4.15MammographyRatesforWomenAged5069,1999/002000/01 and2004/052005/06(Ageadjusted) ................................................................ 113 Figure4.16‘Pap’TestRatesforWomenAged1869,1998/992000/01 and2003/042005/06(Ageadjusted) ................................................................ 115 Figure4.17Top5FemaleCausesofDeathforARHAResidents 19921996,19972001,20022006 ........................................................................118 Figure4.18Top5MaleCausesofDeathforARHAresidents 19921996,19972001,20022006 ......................................................................119 Figure4.19PrematureMortalityRates/1000Residentsagedunder75 19962005(AgeandSexAdjusted) ................................................................... 121 Figure4.20PrematureMortalityRates/1000Residentsagedunder75 byARHADistrict19962005(AgeandSexAdjusted) .......................................122 Figure4.21PrematureMortalityRates/1000Residentsagedunder75 byARHADistrictbyGender19942003(AgeAdjusted)....................................123 Figure4.22PotentialYearsofLifeLost(PYLL)per1000Residentsaged 17419962000and20012005(AgeandSexAdjusted).................................. 125 Figure4.23PotentialYearsofLifeLostbyGender19942003(AgeAdjusted) .................. 126 Table4.1FiveYearMortalityRateforthosewithandwithoutHypertension 2001/022005/06(AgeAdjusted) .......................................................................... 81 Table4.2FiveYearMortalityRateforthosewithandwithoutIschemic HeartDisease(IHD)2001/022005/06(AgeAdjusted).........................................83 Table4.3AMI30DayInHospitalMortality2003/042007/08(RiskAdjusted)...................85 Table4.4AMIHospitalReadmission2004/052007/08(RiskAdjusted) .............................85 Table4.5CardiacRevascularizationInterventionRates/100,00o (Age20+)(AgeStandardized)2003/04and2007/08 ........................................... 90 Table4.6Stroke30DayInHospitalMortality2003/042007/08(RiskAdjusted) .............. 91 Table4.7FiveYearMortalityRateforthosewithandwithoutDiabetes 2001/022005/06(AgeAdjusted)..........................................................................95 Table4.8TotalRespiratoryMorbidityTreatmentPrevalence2000/01 and2005/06(AgeandSexAdjusted)................................................................... 99 Table4.9FiveYearMortalityRateforthosewithandwithoutTotal RespiratoryMorbidity(TRM)2001/022005/06(AgeAdjusted)........................101 Table4.10AsthmaPrevalence–AgeStandardizedCases per1,000Residents20022007 ............................................................................101 Table4.11FiveYearMortalityRateforthosewithandwithoutArthritis 2001/022005/06(AgeAdjusted)....................................................................... 105 Table4.12FiveYearMortalityRateforthosewithandwithout Osteoporosis2001/022005/06(AgeAdjusted)................................................ 107 Table4.13ARHACommunityCancerProgramStatistical Summary01/04/200931/12/2009 ..............................................................108 Table4.14MaleCancerIncidence/100,00020002002and 20032005bySite(AgeAdjusted).....................................................................109 Table4.15FemaleCancerIncidence/100,00020002002and20032005 bySite(AgeAdjusted).........................................................................................111 Table4.165YearRelativeCancerSurvival19951999and20002004 ................................. 112 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 Table4.17MammographyRatesforWomenAged5069,2004/052005/06 and2006/072007/08(CrudeValues)..................................................................114 Table4.18‘Pap’TestRatesforWomenAged1569,2003/042005/06 and2005/062007/08(CrudeValues)................................................................116 Table4.19UnintentionalInjuryDeathrate/100,000,20022006(AgeAdjusted) ............. 120 Table4.20LifeExpectancy19962000and20012005......................................................... 124 Table4.21PYLLper1,000ARHAResidents20022006(CrudeValues)............................... 126 Chapter5:PrimaryCare Figure5.1PhysicianVisitsbyCauseBrandonandRuralSouth.............................................132 Figure5.2PhysicianUse2003/2004(AgeAdjusted)............................................................ 133 Figure5.3AmbulatoryVisitRates2000/2001and2005/2006(AgeandSexAdjusted) ..... 134 Figure5.4AmbulatoryConsultationRateperResident2000/01 and2005/06(AgeandSexAdjusted) ................................................................. 136 Figure5.5ContinuityofCareRates1999/002000/01 and2004/052005/06(AgeandSexAdjusted)................................................... 137 Figure5.6AmbulatoryVisitRatestoSpecialists2000/2001 and2005/2006(AgeandSexAdjusted) ............................................................ 139 Figure5.7RegionalTelehealthEvents2002/032008/09..................................................... 142 Table5.1ARHAPrimaryCareClinicsandScreensCompleted04/200808/2009................. 131 Table5.2LocationofVisitstoGP/FP2000/01and2005/06 ................................................. 135 Table5.3LocationofVisitstoSpecialists2000/01and2005/06.......................................... 140 Table5.4ARHAHealthLinksCallVolumesbyGender20052009 ...................................... 143 Chapter6:PreHospitalandHospitalBasedCare Figure6.1EMSCallVolumes20052008PrimaryandIFT.................................................... 145 Figure6.2OperationalHospitalBedsper1000residents2001 and2006(AcuteandOther) .............................................................................. 150 Figure6.3HospitalSeparationRates/1000(AgeandSexAdjusted) .................................. 152 Figure6.4HospitalEpisodeRates/1000ResidentsAges019(AgeandSexAdjusted) ..... 154 Figure6.5WhereARHAHospitalPatientsCameFrom:Separations20052006 ............... 155 Figure6.6WhereARHAResidentsWentforHospitalSeparations20052006.................. 156 Figure6.7HospitalDaysUsedRates/10002000/01 and2005/06(AgeandSexAdjusted) ................................................................. 158 Figure6.8HospitalDaysUsedforShortStays(<14Days)Rates/10002000/01 and2005/06(AgeandSexAdjusted).............................................................. 159 Figure6.9HospitalDaysUsedforLongStays(>=14Days)Rates/10002000/01 and2005/06(AgeandSexAdjusted)..............................................................160 Figure6.10RateofHospitalizationforAmbulatoryCareSensitiveConditions2000/01 and2005/06per1000ResidentsAged075(AgeandSexAdjusted) ............161 Figure6.11RateofHospitalizationforInjuries2000/01and2005/06per 1000Residents(AgeandSexAdjusted)........................................................... 162 Figure6.12Tonsillectomy/AdenoidectomyRates/1000Aged0141996/972000/01 and2001/022005/06(AgeandSexAdjusted) ................................................. 164 Figure6.13HysterectomyRate2002/03–2006/07/1000Aged25+(AgeAdjusted)..........166 Figure6.14CaesareanSectionRate1996/972000/01and2001/022005/06 AgeAdjusted)...................................................................................................168 Figure6.15AcuteCareFacilityFallsJanJun2006JanJun2009........................................ 174 PG:IX PG:XLISTOFFIGURESANDTABLES Figure6.16AcuteCareFacilities–MedicationIncidentsper1000InpatientDays 2004/20052008/2009 ...................................................................................... 175 Table6.1AcuteCareBedOccupancy20042008 .................................................................. 151 Table6.2CrudeHospitalSeparationRates2000/01and2005/06....................................... 153 Table6.3WhereARHAResidentsWentforHospitalSeparations/Days20052006 ........ 157 Table6.4WhereARHAFacilityClientsCameFromforHospitalSeparations/ Days20052006................................................................................................... 157 Table6.5HospitalDaysUsed2000/01and2005/06CrudeRates ....................................... 157 Table6.6SurgicalInterventionsinARHAFacilities2007/20082008/2009 ........................ 163 Table6.7ARHAResidentBirthsbyRHA(DeliveryHospitalLocation) 2004/20052007/2008.......................................................................................... 167 Table6.8RiversRehabilitationUnitStatistics2006/072008/09 .......................................169 Table6.9HipandKneeReplacementsRate/1000Residentsaged40+ 1996/972000/01and2001/022005/06(AgeandSexAdjusted) ...................... 170 Chapter7:PublicHealth Figure7.1TeenPregnancyinWomenAged1519(cruderateper1000) ............................ 179 Figure7.2RegionalBirthrateper1000FemalesAged1549,2000/012006/07 .................180 Figure7.3PercentofPretermBirths(SexAdjusted),1996/97–2005/06 (Pretermislessthan37weeksgestation) .......................................................... 183 Figure7.4TeenBirthRateofWomenAged1519(Ageadjustedrateper1000) ............... 184 Figure7.5StillbirthRateper1000,19962000and20012005 ............................................186 Figure7.6InfantMortalityRate(Underoneyear)– CrudeRateper1000births19962000and20012005...................................... 187 Figure7.7ChildMortality(Aged019)per100,00019962000and20012005..................188 Figure7.8CausesofInjuryMortalityinChildrenuptoAge19,20012005(Manitoba) .....189 Figure7.9Percentoffamilieswithnewbornsscreened20032006....................................191 Figure7.10PercentofFamiliesScreenedwith3ormoreRiskFactors 20032006byDistrictofResidence .................................................................... 192 Figure7.11CompleteImmunizationRatesforInfantsAged1Year(sexadjusted) ........... 201 Figure7.12CompleteImmunizationRatesforChildrenAged2Years(sexadjusted) ......202 Figure7.13CompleteImmunizationRatesforChildrenAged7Years(sexadjusted) ......203 Figure7.14CompleteImmunizationRatesforChildrenAged11Years(sexadjusted) .....204 Figure7.15InfluenzaImmunizationRatesforResidentsaged65+Years (ageandsexadjusted)2000/01and2005/06................................................... 206 Figure7.16CumulativePneumococcalImmunizationRatesfor Residentsaged65+Years(ageandsexadjusted)2000/01and2005/06 ........207 Table7.1PregnancyRate/1000byAgeGrouping2004/052006/07.................................... 178 Table7.2AgesatFirstPregnancyRate/1000byAgeGrouping2001/022003/04............... 178 Table7.3LowBirthWeight(<2500gms)20022007 .............................................................181 Table7.4HighBirthWeight(>4500gms)20022007 ............................................................181 Table7.5SizeforGestationalAge(SexAdjusted)1996/972005/06 .................................. 182 Table7.6PercentofFamiliesScreenedwith3ormoreRiskFactors20032006 ................191 Table7.7FamiliesFirstRiskFactors20032006 ................................................................... 193 Table7.8URISInterventions20072010byHealthCareNeed............................................199 Table7.9ImmunizationRates‘CompleteforAge’111 ........................................................205 Table7.10CommunicableInfectionsbyType (NewCases5yearaverage20022006)............................................................ 209 Table7.11WestNileCasesbyRegionalHealthAuthority2007 ........................................... 210 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 Table7.12SexuallyTransmittedInfectionsbyTypebyGender (5yearaverage20022006,rateper1,000) ......................................................... 211 Chapter8:MentalHealth Figure8.1SF36GeneralMentalHealthScaleAged12+ (AgeandSexAdjustedCCHS20032005)............................................................220 Figure8.2Life(L)Ages15+andWork(W)Ages1575Related,SelfPerceivedStress (AgeandSexAdjustedCCHS20012005) ............................................................221 Figure8.3TreatmentPrevalenceofMentalIllnessDisordersintheAssiniboineRHA (Aged10+)1996/97–2001/02and2001/022005/06(AgeandSexAdjusted) ....224 Figure8.4TreatmentPrevalenceof‘CumulativeDisorders’(Aged10+) 1996/97–2001/02and2001/022005/06(AgeandSexAdjusted)....................... 225 Figure8.5TreatmentPrevalenceofAnxietyDisorders(Aged10+) 1996/97–2001/02and2001/022005/06(AgeandSexAdjusted).......................226 Figure8.6TreatmentPrevalenceofDementia(Aged10+)1996/97–2001/02 and2001/022005/06(AgeandSexAdjusted) ..................................................... 227 Figure8.7TreatmentPrevalenceofDepression(Aged10+)1996/97–2001/02 and2001/022005/06(AgeandSexAdjusted) .....................................................228 Figure8.8TreatmentPrevalenceofPersonalityDisorders(Aged10+)1996/97–2001/02 and2001/022005/06(AgeandSexAdjusted) .....................................................229 Figure8.9TreatmentPrevalenceofSchizophrenia(Aged10+)1996/97–2001/02 and2001/022005/06(AgeandSexAdjusted) .....................................................230 Figure8.10TreatmentPrevalenceofSubstanceAbuse(Aged10+)1996/97–2001/02 and2001/022005/06(AgeandSexAdjusted) ......................................................231 Figure8.11AllCauseHospitalSeparationRatesforMales(Aged10+)Withand WithoutCumulativeDisorders1997/98–2001/02(AgeAdjusted) ..................... 233 Figure8.12AllCauseHospitalSeparationRatesforFemales(Aged10+)Withand WithoutCumulativeDisorders1997/98–2001/02(AgeAdjusted) .....................234 Figure8.13PhysicianVisitsRatesforMentalIllnessDisorders 1997/982001/02(AgeAdjusted) .......................................................................236 Figure8.14AntidepressantUse2000/01and2005/06(AgeandSexAdjusted)................. 237 Figure8.15AntidepressantPrescriptionFollowUp1998/992000/01 and2003/042005/06..........................................................................................238 Figure8.16AntidepressantPrescriptionUseRate/1000Aged0191998/992000/01 and2003/042005/06(AgeandSexAdjusted)..................................................239 Figure8.17PsychostimulantPrescriptionUseRate/1000Aged5192000/01 and2005/06(AgeandSexAdjusted) ................................................................240 Figure8.18SuicideRate/1000Aged10+19962000and20012005 (AgeandSexAdjusted)......................................................................................242 Figure8.195YearMortalityRate2001/20022005/06Aged19+WithandWithout CumulativeMentalIllness(AgeandSexAdjusted)............................................243 Table8.1ChildandAdolescentServicesProgramStatistics2006/072008/09 .................. 215 Table8.2AdultMentalHealthServicesProgramStatistics2006/072008/09 ................... 216 Table8.3MentalHealthPromotionActivities .................................................................... 218 Table8.4TreatmentPrevalenceofMentalIllnessDisordersintheAssiniboineRHA (Aged10+)1996/97–2001/02and2001/022005/06(CrudePercent) ................. 223 Table8.5PercentageofAllCauseHospitalSeparationsfor MentalIllness1997/982001/02............................................................................. 235 Table8.6AllCauseHospitalSeparationRatebyDisorder1997/98–2001/02 (AgeAdjusted) ...................................................................................................... 235 PG:XI PG:XIILISTOFFIGURESANDTABLES Chapter9:HomeBasedandLongTermCare Figure9.1NewHomeCareCases1999/002000/01and2003/042004/05 (AgeandSexAdjusted).......................................................................................246 Figure9.2OpenHomeCareCases1999/002000/01and2003/042004/05 (AgeandSexAdjusted).....................................................................................247 Figure9.3PrescribingofBenzodiazepinesinCommunityDwellingSeniors 2000/01and2005/06..........................................................................................250 Figure9.4PersonalCareHomeBeds/1000Residentsaged75+1999/2000 2000/2001(00)and2004/20052005/2006(05) ................................................254 Figure9.5LevelofCareonAdmissiontoPCH,Residentsaged75+ 1999/20002000/2001(00)and2004/20052005/2006(05)..............................256 Figure9.6PrescribingofBenzodiazepinesinPersonalCareHomes 2000/01and2005/06 ...........................................................................................259 Figure9.7PersonalCareHomes–ResidentFallsper1000ResidentDays 2004/20052008/2009......................................................................................... 260 Figure9.8PersonalCareHomes–MedicationIncidentsper1000ResidentDays 2004/20052008/2009.......................................................................................... 261 Table9.1HomeCareClosingRates1999/002000/01and 2003/042004/05(AgeandSexAdjusted) .............................................................248 Table9.2AverageLengthofHomeCareCases1999/002000/01and 2003/042004/05(AgeandSexAdjusted) ...........................................................249 Table9.3MedianWaitTime(weeks)fromAssessmentto Admission2004/20052005/2006 ........................................................................ 257 Table9.4MedianLengthofStay(Years)byLevelofCareonAdmissiontoPCH, 1999/20002000/2001and2004/20052005/2006 ................................................258 Table9.5PalliativeCareProgramEnrolments2006/20072008/2009................................262 Chapter10:HealthAuthorityCharacteristics Figure10.1Expenditurebyarea2008/2009FiscalYear .......................................................265 Table10.1ClientSatisfactionwithOverallQuality .............................................................. 268 Table10.2StaffInfluenzaImmunization20042008.............................................................271 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:XIII ExecutiveSummary Health contributes to the vitality of our communities. A vibrant healthy population leads to growth and progress. There are many factors that influence health, of which health care is one part. Regional health authorities in Manitoba are responsible for assessing the health of the population on a regular basis. It is important to do this in order to identify strengths, determine health care needs, understand which groups are at greatest risk, identify health care priorities, and monitor our progress toward achieving improved health and health care outcomes. This report summarizes the findings from the third comprehensive community health assessment (CHA) for the Assiniboine Regional Health Authority. Community health assessment involves a variety of activities, including: Collection and analysis of statistical/utilization/health status data; and Engagement of the community, partner organizations, and regional staff through a range of activities including focus groups, key informant interviews, and surveys. The main purpose of this report is to identify changes and trends in health status, health behaviours, and health care use of residents living in the Assiniboine region. This report also provides some insight into the social, physical, and economic environments that can affect the health and quality of life of residents. Potential disparities in health status and health care access are discussed. These findings will provide the groundwork for strategic and program planning in the regional health authority. The information presented might be of value for other groups that are interested in improving health and quality of life in our communities. In order for the information to be meaningful to staff and others interested in health care, it is organized in such a way that it corresponds with the health services offered by the Assiniboine Regional Health Authority. The Assiniboine Regional Health Authority provides health services in the following areas: primary care, pre-hospital care, acute care, transition care, rehabilitation, public health, mental health, home care, long term care, spiritual health, palliative care, health promotion, and the many functions that fall within and support these areas. WhatWeHaveLearned The population of the Assiniboine region is changing. While the population has been steadily declining in recent years, many of our communities have experienced a growth in immigration. If current trends continue, the regional population is projected to decrease until 2020. After that, it is projected that the population will increase by approximately 4% by 2036. Culture has a strong influence on health and access to heath care. The growing diversity in communities can lead to challenges in accessing health care as new immigrants attempt to seek care in an unfamiliar health care system in a different language. First PG:XIVEXECUTIVESUMMARY Nation and Métis residents may also experience challenges in accessing health care due to language, transportation, and complexity of eligibility criteria for benefits. Other cultural groups may experience difficulty accessing services due to transportation and language barriers. While our communities possess many strengths, such as good social support, high rates of high school completion, and low unemployment, there are opportunities to improve. Access to transportation, suitable housing, supportive housing for seniors, and funded counselling services were identified as needs by community, partners, and staff. According to community engagement results, there is room for improving health behaviours, particularly among children and youth. Community members are advocating for access to affordable healthy options, such as recreation programs and facilities, as well as healthy food choices. Food security is a growing issue. Partners identified concerns about alcohol use and management of clients with addictions. Generally, male Assiniboine residents are about as healthy as the average Manitoba male, while Assiniboine females tend to be healthier than the average Manitoba female. Injury rates, tend to be higher for Assiniboine males than the Manitoba average. The prevalence of some health conditions has decreased over time, but others have been increasing. Increases may be partly due to enhanced screening and diagnosis. DiseasetrendsinprevalenceoverfiveyearsfortheAssiniboineRHA. Diseasesthatwentdown Prevalenceforthe periodending 2000/01 %Changeoverfive years 2005/06 Stroke 4/1000 3.1/1000 Ø 22.5 HeartAttack 5.1/1000 4.6/1000 Ø 13.7 RespiratoryDiseases 11% 9.8% Ø 11.0 Diabetesrelatedlowerlimbamputation 1.4% 1.2% Ø 9.1 IschemicHeartDisease 7.4% 7.2% Ø 2.7 Arthritis 19.6% 19.1% Ø 2.6 Dementia 8.3% 8.1% Ø 2.4 Osteoporosis 9.7% 12.7% × 30.9 Diabetes 6.5% 8% × 23.0 Hypertension 20.3% 23.7% × 16.7 Depression 14.4% 16.4% × 13.9 Anxiety 4.9% 5.4% × 10.2 Cumulativementalillness 18.8% 20.4% × 8.5 4.3% 4.3% 0.0 Diseasesthatwentup SubstanceAbuse MCHPRHAINDICATORSATLAS2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:XV Circulatory conditions continue to be the leading cause of death among Assiniboine residents, with higher stroke mortality rates for Assiniboine residents than the Manitoba average. The Assiniboine region is developing new protocols and strategies for the prevention and management of strokes and heart conditions. Based on the following diagram, which depicts the proportion of Assiniboine residents receiving various types of health care services, it appears that the majority of people within the region access services which fall within the realm of primary care. This is not inclusive of all services because there are a large number of people who access other programs such as Public Health and Mental Health that are not included in available data. 2.3% Inhomecare 8.3%hospitalized 13.1%of75+inPCH 68.8%gotaprescription 81.6%visitedadoctor MCHPRHAINDICATORSATLAS2009 Demand for many health care services is increasing, such as EMS call volumes, public health programs (postpartum standards, Families First screening, URIS clients, additions to the immunization schedule, and communicable disease follow-up), mental health resources, and palliative care supports. With declining populations and other factors, the region has been facing human resource challenges in almost every area, mostly for providers such as doctors, nurses, EMS attendants, and health care aides. Lack of staffing can affect the continuity of service. Maintaining access to primary care physicians, acute care, and emergency care are among the top concerns of community members. Despite increasing demands and chronic staffing challenges, the Assiniboine region continues to strive to provide quality care. Many program activities have achieved positive outcomes, such as low teen pregnancy rates, high child immunization rates, improved access to cancer screening for women, and high satisfaction ratings from clients who have used our services. PG:XVIEXECUTIVESUMMARY Because the community and our staff are the heart of the region, communication and employee worklife are priorities for the Assiniboine region. Using various formats and venues, the region provides information about programs and services to the public and staff. Staff satisfaction is assessed on a regular basis. The region is offering an increasing number of continuing education opportunities to staff using innovative approaches like eLearning. Conclusion The Assiniboine region remains committed to providing safe, quality care. Addressing challenges related to staffing is a priority through proactive planning and recruitment and retention efforts. The Primary Care program is improving access to health care providers, especially for women’s health issues. Prevention is a priority, with many community-based initiatives happening to improve healthy choices. The Assiniboine region continues to monitor the health and health care use of residents, developing strategies to enhance existing prevention activities, and to improve quality of care for clients according to the latest guidelines. Through the community health assessment, new partnerships have been formed that we hope will lead to better health for our residents. The results of this report will allow for reflection on the state of the region based on evidence which includes the perspective of the community, partners, and staff. This evidence will be used in establishing the strategic directions of the Assiniboine region for the next five years. Ifyouwouldlikemoreinformationaboutthecommunityhealthassessment, pleasecontact:[email protected] RegionalOfficeat(204)7594500. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:1 Introduction Whatiscommunityhealthassessment? Community health assessment (CHA) is a dynamic, ongoing process that regional health authorities undertake in order to determine the strengths and needs in communities, as well as to identify community-wide health priorities. The information collected is analyzed and reported in a way that creates an understanding of the health of the population and factors that are influencing health among residents of the region. The community health assessment uses a population health perspective, which takes into account the determinants of health as well as the characteristics and performance of the health system. This approach is meant to assess and positively influence the conditions that affect the health and quality of life of a population. Health is considered more than just the absence of disease, but is also a resource for living that encompasses the whole person. “Community”canbedefinedasallpersonslivinginacertaingeographicarea,suchas a town or municipality. It may also refer to groups of people with common characteristicsorinterests,suchaswomen,youth,seniors,culturalgroups,orthose livingwithspecifichealthissues. The regional health authorities work collaboratively with Manitoba Health to identify common relevant indicators that are reviewed through the community health assessment process. This joint approach allows for some degree of comparability across the province yet is flexible enough to allow for each regional health authority to develop a unique way of conducting its community health assessment. This report is the culmination of that process, including information about the health of the residents of the Assiniboine Regional Health Authority (ARHA) and about the community’s capacity to improve the lives of residents. By assessing the population’s health status, health care use, and the performance of the health system, the community health assessment also provides information about ways to improve the responsiveness of the health system. The results from the community health assessment are provided to the regional health authority Board as a foundation for strategic planning. These findings are intended to provide the basis for discussion and future action planning, either by communities, partner organizations, or regional programs and services. PG:2 INTRODUCTION Methods A large portion of the comprehensive CHA process involves the collection and review of quantitative data. Much of the data is provided by the Health Information Management Branch of Manitoba Health and the Manitoba Centre for Health Policy. Other data come from provincial partners, such as CancerCare Manitoba. Data collected by the region is also included. The community engagement process was a crucial aspect of community health assessment, which involved meetings in 10 communities across the region: Brookdale, Cartwright, Cromer, Cypress River, Eden, Foxwarren, Kenton, Minto, Newdale, and Pierson. Through these meetings, community members discussed a series of questions about the health and quality of life of people in the region. A second round of meetings was offered in the same communities in order to validate the information gathered. Other meetings and interviews were held with partner organizations, major workplaces, youth, and cultural groups (new immigrants, Hutterian, and Aboriginal residents). Staff of the Assiniboine region were also included in the community health assessment. A staff survey was available for any staff member to complete, either online or on paper. Focus groups were held with many staff groups within the region in order to identify program-specific information. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:3 DataPresentationandInterpretation Most indicators in this report are presented using a population–based approach. This means that the rates or the prevalence shown are based upon virtually every person living in Manitoba and excludes only those in Federal penitentiaries, members of the Canadian Armed Forces, and the RCMP. The indicators in this report are based upon where people live, not where they received services. For example, a person living in the Assiniboine region may be hospitalized in Winnipeg, but the hospitalization is attributed back to the rate for the Assiniboine RHA. Thus, the results show the health and healthcare use patterns of the population living in the ARHA, no matter where they receive their care. In all cases, the latest available information is presented. Graphs and tables have been labelled and ordered in a consistent fashion throughout the report with sources clearly defined. GeographicBoundaries In the majority of cases the quantitative data is presented for the eleven regional health authorities of Manitoba, and where available, or significant, is split by gender and broken down into the Assiniboine RHAs six districts (the geographic boundaries including the municipalities and towns that make up these districts are outlined in Chapter 1). Also shown is the Manitoba average and values for aggregate RHAs to allow for comparisons across areas of similar health status to the Assiniboine RHA. The aggregate areas used are: Rural South which includes Assiniboine, Central and South Eastman RHAs Mid, comprised of North Eastman, Interlake and Parkland RHAs North, comprised of Nor-Man, Burntwood and Churchill RHAs When reading this report, unless explicitly specified otherwise, you should assume that‘theregion’istheareacoveredbytheAssiniboineRegionalHealthAuthorityand that ‘residents’ are the people living within the boundaries of the Assiniboine RegionalHealthAuthority. PG:4 INTRODUCTION RegionalHealthAuthoritiesofManitobaandAggregateRHABoundaries ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:5 RatesandPrevalence In the majority of charts or tables, data is presented as a rate or prevalence. Prevalence refers to the proportion of the population that has a certain condition, either at a given point in time (point prevalence) or over a period of time (period prevalence). It is an indication of how common the condition is and, therefore, has implications for the provision of services. Most indicators in this report use the concept of period prevalenceover one–year, three–year, or five–year periods. In contrast, a rate refers to a change in state over time and is used to express the frequency of events during a given period. Many health–related events can happen to a given person more than once. For example, the physician visit rate shows how often residents visit physicians each year. Where an indicator covers a period longer than one year, the rate is annualized— that is, given as an annual average. AdjustedRatesandCrudeValues Most of the indicators in this report are labelled as ‘age–and sex–adjusted’ rates because the results have been statistically adjusted to account for the different age and sex composition of the populations living in different areas. This adjustment allows for fair comparisons among areas with different population characteristics. Adjusted rates show what that area’s rate would have been if the area’s population had the same age and sex composition as the Manitoba population. In some cases ‘crude values’ are additionally presented in order to indicate the actual number of events that occurred (e.g. residents suffering from a particular condition) within the region and to represent the possible burden of illness to the Assiniboine region in particular. Whenreadingthisreport,ifthenarrativereferringtoachartortablesuggeststhata difference is ‘significant’ then you should imply that the difference is ‘statistically significant’andnotlikelytobeanannualorperiodfluctuation. Limitations The community engagement meetings were intended to gain an understanding of health and health care from the perspective of a wide range of residents of the region. Municipal partners across the region were engaged to assist with identifying people from their communities to participate. The people identified were to be representative of the people who live in the community, including a variety of demographic characteristics. PG:6 INTRODUCTION Although the intent was to obtain a good cross-section of individuals in communities, it was not always possible to recruit people who represented every aspect of a community. The people who participated spoke from their particular perspective and we recognize and respect that. We also recognize that vulnerable populations may not always be represented at community meetings and made attempts to obtain their perspective by other means. The Adult Health Survey was conducted using a random sample in certain communities and therefore may not be representative of every community across the region. The results reflect the perspective of the people who responded. The Youth Health Survey was done as a census sample, meaning that every student whose parents consented to their participation had an opportunity to complete the survey. The intent is not for schools to compare themselves to other schools in the region or province, since the results have not been adjusted to reflect the particular characteristics of the students from each school. Data presented in this report from the Canadian Community Health Survey (CCHS) conducted by Statistics Canada is comprised of a sample of Manitobans selected to be representative of the provincial population. It is not based on the entire population and therefore needs to be interpreted with some caution. Specifically, it excludes residents living in First Nations communities. In addition, the data collection involves interviewers asking questions of participants, which may be affected by personal bias, recall error, and self-serving responses. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:7 Chapter1:Population The region’s population structure is an important factor when considering the type of health service delivery that may be required and the areas which may require more or less emphasis. The Assiniboine Regional Health Authority covers an area in the southwest corner of Manitoba, surrounding, but excluding, the urban centre of Brandon. It is split into six geographic districts and covers an area of 32,134 square kilometres. Figure1.1ARHAGeographicBoundaries PG:8 CHAPTER1:POPULATION Table1.1TownsandMunicipalitiesoftheAssiniboineRegionalHealthAuthority North1 East2 RMofArchie RMofArgyle RMofBirtle RMofOakland TownofBirtle VillageofWawanesa RMofBoulton* RMofRiverside RMofEllice RMofRoblin VillageofSt.Lazare VillageofCartwright RMofHamiota RMofSouthCypress VillageofGlenboro VillageofHamiota RMofMiniota RMofSouthNorfolk RMofRossburn VillageofTreherne TownofRossburn RMofStrathcona RMofRussell RMofTurtleMountain* TownofRussell TownofKillarney* VillageofBinscarth RMofVictoria RMofShellmouth* RMofShoalLake West1 TownofShoalLake RMofCameron RMofSilverCreek TownofHartney BirdtailSiouxFirstNation RMofGlenwood GamblersFirstNation TownofSouris WaywayseecappoFirstNation RMofMorton TownofBoissevain North2 RMofSifton RMofBlanshard TownofOakLake RMofWhitewater RMofClanwilliam TownofErickson RMofWinchester RMofHarrison TownofDeloraine RMofMinto TownofMinnedosa West2 RMofOdanah RMofAlbert RMofSaskatchewan RMofArthur TownofRapidCity TownofMelita RMofStrathclair RMofBrenda VillageofWaskada RMofParkMarquette KeeseekooweninFirstNation RMofDaly RollingRiverFirstNation TownofRivers RMofEdward East1 RMofPipestone RMofGlenella RMofWallace RMofLangford TownofVirden TownofNeepawa VillageofElkhorn RMofLansdowne RMofWoodworth RMofNorthCypress SiouxValleyFirstNation TownofCarberry CanupawakpaFirstNation RMofRosedale *TownsandmunicipalitiesshownareasreportedbyManitobaHealth.TheRMofBoultonandRMof ShellmouthhavemergedtoformtheRMofShellmouthBoulton.TheRMofTurtleMountainandthe TownofKillarneyhavemergedtoformtheRMofKillarneyTurtleMountain. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:9 Population,Structure,andChange The population of the region in June of 2008 was 67,819, around 5.7% of the Manitoba population. This represents a decline of 2,033 from the same time in 2003. The gender split is fairly even at 49.7% male and 50.3% female with 19.5% being 65 years of age or older. The breakdown of the region’s population by age group and sex for both June 2003 and June 2008 is shown below. A more comprehensive population count containing a breakdown of the region’s populationbymunicipalityanddistrictcanbefoundinAppendix1. Table1.2AssiniboineRegionalHealthAuthorityPopulationJune2003,2008 04 59 1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7074 7579 8084 8589 90+ POPULATIONJUNE2003 MALE FEMALE 1,881 1,768 2,254 2,120 2,644 2,538 2,791 2,567 2,231 1,974 1,836 1,657 1,747 1,780 2,058 2,047 2,572 2,536 2,721 2,545 2,307 2,229 2,088 1,990 1,718 1,799 1,491 1,571 1,453 1,598 1,366 1,496 910 1,400 499 891 249 560 POPULATIONJUNE2008 MALE FEMALE 1,974 1,829 1,980 1,859 2,269 2,167 2,581 2,394 2,178 1,948 1,754 1,637 1,670 1,671 1,749 1,830 2,020 2,076 2,550 2,511 2,695 2,552 2,303 2,286 2,114 2,012 1,665 1,701 1,306 1,431 1,190 1,371 973 1,228 499 978 247 621 SOURCE:MANITOBAHEALTHINFORMATIONMANAGEMENT2009 PG:10 CHAPTER1:POPULATION The population of the region is fairly evenly split between males and females, however there are slightly higher proportions of males in the 0-24 and 45-55 age brackets and as would be expected there are considerably higher numbers of females in the 70+ age group. Figure1.2ARHAPopulationPercentagebyAgeandGenderJune1,2008 ARHAMaleJune2008 ARHAFemaleJune2008 FemaleMaleVariance 5.00% 4.00% 3.00% 2.00% 1.00% 0.00% 04 59 1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7074 7579 8084 8589 90+ 1.00% SOURCE:MANITOBAHEALTHINFORMATIONMANAGEMENT2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:11 The percentage change in the region’s population made up by each age group and gender shows a decline in specific age groups between June 2003 and June 2008. Both males and females have shown a decline in the 5-19 and 30-44 age groups. There has been a relatively large increase in the 50-69 age bracket for both genders but more so for males. Other age brackets have remained relatively stable over the five year period. Figure1.3ARHAPercentagePopulationChangebyAgeandGenderJune1,2003 June12008 ARHAMaleChange ARHAFemaleChange 0.80% 0.60% 0.40% 0.20% 0.00% 04 59 1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7074 7579 8084 8589 90+ 0.20% 0.40% 0.60% 0.80% 1.00% SOURCE:MANITOBAHEALTHINFORMATIONMANAGEMENT2009 PG:12 CHAPTER1:POPULATION PopulationPyramids The structure of the region’s population, its relationship to the rest of Manitoba, and how it has changed over time, is most easily demonstrated by the use of population pyramids. A population pyramid is a graph showing the age and sex distribution of a population within five year age groups. A population pyramid for the Assiniboine RHA in June of 2008 compared to that of Manitoba at the same time is shown in Figure 1.4, below. In comparison to Manitoba, the population of the region is generally considerably older, with a much higher proportion in the 50 and over age bracket and less in 20-44 and 0-10 age brackets. Figure1.4AgeProfileoftheAssiniboineRegionalHealthAuthorityandManitoba,2008 Assiniboine,Jun2008 90+ 8589 8084 7579 7074 6569 6064 5559 5054 4549 4044 3539 3034 2529 2024 1519 1014 59 04 MBJun2008 Male 5% 4% Female 3% 2% 1% 0% 1% 2% 3% 4% 5% SOURCE:MANITOBAHEALTHINFORMATIONMANAGEMENT2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:13 From June 2003 to June 2008 there has been a noticeable increase in the region’s population between the ages of 50-64 and a decline in the population from 0-19. This population structure change is not particular to the region but is reflected in Manitoba as a whole. Figure1.5AgeProfileoftheAssiniboineRegionalHealthAuthority,2003and2008 Assiniboine,Jun2008 90+ 8589 8084 7579 7074 6569 6064 5559 5054 4549 4044 3539 3034 2529 2024 1519 1014 59 04 Assiniboine,Jun2003 Male 5% 4% Female 3% 2% 1% 0% 1% 2% 3% 4% 5% SOURCE:MANITOBAHEALTHINFORMATIONMANAGEMENT2009 PG:14 CHAPTER1:POPULATION PopulationProjections The Manitoba Bureau of Statistics issued a report in April of 2008 containing population projections for the region up until June of 2036. The report suggests that the region’s population will remain fairly stable gradually declining until 2020 and then increasing with an overall change of around +4% by 2036. The structure of the population is likely to change, with a significant increase in the population 65 and over from 19.9% in 2006 to 22.5% by 2036. Births per year in the region are expected to increase gradually from the 2006 value of 780, to peak at around 950 a year in 2020 and taper off to 830 a year by 2036. Figure1.6ARHAPopulationProjectionsbyAgeGroup20062036 ARHAAGES014 ARHAAGES2064 ARHAAGES65+ 75,000 70,000 65,000 60,000 55,000 50,000 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 2035 2036 2034 2033 2031 2032 2030 2029 2027 2028 2025 2026 2024 2023 2021 2022 2020 2019 2017 2018 2015 2016 2014 2013 2011 2012 2010 2009 2007 2008 2006 0 SOURCE:MANITOBABUREAUOFSTATISTICS2008 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:15 The following table shows the actual population structure of the region in 2006 compared to that of Manitoba as a whole alongside the projected structure for 2036. Table1.3ARHAandManitobaPopulationStructure2006Actualand2036Projected 014 1519 2054 5564 6574 7584 85andover ASSINIBOINERHA ACTUAL PROJECTED JUNE2006 JUNE2036 18.2% 18.7% 7.5% 6.9% 42.7% 43.4% 12.2% 8.6% 8.8% 9.1% 7.2% 8.9% 3.3% 4.5% MANITOBA ACTUAL PROJECTED JUNE2006 JUNE2036 19.6% 18.3% 7.3% 6.6% 48.8% 46.6% 10.7% 10.2% 6.7% 8.9% 4.9% 6.7% 2.0% 2.8% SOURCE:MANITOBABUREAUOFSTATISTICS2008 DependencyRatio The projected increase in the elderly and child population is likely to have a significant impact on the region’s dependency ratio. Dependency ratio measures the proportion of the population under the age of 15 and over the age of 65 compared to those considered to be of a working age (15-64). It is generally considered that the region’s dependency ratio is a reasonable measure of the likely demands on its health services since those residents under the age 15 and over the age of 64 are more likely to require health services. Children and the elderly are also more likely to be socially and/or economically dependent on those of working age. Using population projection numbers provided by the Manitoba Bureau of Statistics developed in 2008, it is possible to predict how the region’s dependency ratio will change over the 30 year period 2006 to 2036. The region’s already high dependency ratio of around 60.2 in 2006 (the Manitoba average is 51.6) is projected to steadily increase to over 75 by 2030. This is likely to significantly increase the demands on the region’s working age population and on its health service. PG:16 CHAPTER1:POPULATION Figure1.7ARHADependencyRatiosActualandProjected20062036 CHILDCOMPONENT AGEDCOMPONENT 90 80 70 60 50 40 30 20 10 2035 2036 2034 2032 2033 2031 2029 2030 2027 2028 2025 2026 2024 2022 2023 2021 2019 2020 2017 2018 2015 2016 2014 2012 2013 2011 2010 2009 2007 2008 2006 0 SOURCE:MANITOBABUREAUOFSTATISTICS2008 When the dependency ratio is split into its two constituent parts; child (0-14) and aged (15-64), it becomes apparent that the main reason for the projected fifteen point increase in overall dependency ratio is due to an increase in the aged component of the population (+10.1) as opposed to the child component (+4.9). ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:17 ChapterHighlights The Assiniboine region has fewer children, fewer adults, and more seniors than Manitoba as a whole. The current population trend in the region has been a decline in population every year. This trend is projected to continue until around 2020, when the population is projected to begin increasing. Population projections by the Manitoba Bureau of Statistics indicate that the overall population will increase by around 4% by 2036 and that the senior’s population (65+) will increase from 19.9% in 2006 to 22.5% by 2036. The region’s already high dependency ratio is projected to increase from just over 60 in 2006 to over 75 by 2030, significantly increasing the demands on the region’s working age population and on its health service. PG:18 CHAPTER1:POPULATION ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:19 Chapter2:SocialandEconomicDeterminantsofHealth Determinants of health are the economic and social conditions that shape the health of individuals and communities as a whole. They are the main factors which influence whether individuals stay healthy or become ill and determine the extent to which a person possesses the physical, social, and personal resources to identify and achieve personal aspirations, satisfy needs, and cope with the environment. There are twelve key social determinants of health: income & social status, healthy child development, education & literacy, employment & working conditions, social support networks, personal health practices & coping skills, social environments, physical environments, biology & genetic endowment, health services, culture, and gender. These determinants are connected, working in concert to determine how healthy or unhealthy we may be. Figure2.1DeterminantsofHealth Culture Gender Physical Environments Biologyand Genetic Endowment Health Services Personal Health Practicesand CopingSkills Social Environment Employment andWorking Conditions HealthyChild Development Social Support Networks Educationand Literacy Incomeand SocialStatus PG:20CHAPTER2:SOCIALANDECONOMICDETERMINANTSOFHEALTH Health care providers, partners and community members have stated that it is important for people to understand the many factors that influence health, of which health services are a very small part. Evidence indicates that the health-related effects of each and every one of these factors equals or exceeds the influence of the “lifestyle” or behavioural risk factors such as tobacco and alcohol use, diet, and physical activity. Culture Culture and ethnicity play an important role in shaping: the way people interact with a health care system; their participation in programs of prevention and health promotion; their access to health information; their health-related lifestyle choices; their understanding of health and illness, and their priorities in the area of health and fitness. Health is also affected by culture through opportunities for social engagement, being able to communicate effectively, and how one is treated by others. The Assiniboine region is becoming increasingly diverse as a result of immigration. Through the community engagement process, community members, and particularly youth, mentioned the need for tolerance and understanding of others. Staff mentioned the importance of practicing cultural sensitivity when working with clients. AboriginalPopulation According to the 2006 Census 9.6% of the region’s residents are Aboriginal. Aboriginal persons are defined as those persons who reported identifying with at least one Aboriginal group (e.g. First Nation, Métis or Inuit) and/or those who reported being a Treaty Indian or a Registered Indian as defined by the Indian Act and/or those who were members of an Indian Band or First Nation. This is an increase from both the 1996 Census value of 6.4% and the 2001 Census value of 8.6% but is still relatively small compared to the average in Manitoba at 11.7% (1996), 14.5% (2001) and 15.5% (2006). The Aboriginal population of the region may be understated to a certain degree because it relies somewhat on self-declaration. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:21 Figure2.2AboriginalPopulation19962006 80% 70% Census1996 Census2001 Census2006 60% AssiniboineRHA:19966.4%20018.6%20069.6% 50% 40% 30% 20% 10% 0% Manitoba Burntwood NorMan Churchill Parkland N.Eastman Interlake Winnipeg Brandon Assiniboine Central S.Eastman SOURCE:STATISTICSCANADACENSUSES19962006 The majority of the Aboriginal population is based in the seven First Nation communities, mostly in the north and west of the region. In addition, there are many Métis people living in communities across the Assiniboine Region, especially in the northwest and southeast of the region. There are a number of Manitoba Métis Federation Locals in the Assiniboine region, with an increasing number of people embracing their Métis heritage. Prior to engaging the First Nations people of the Assiniboine region to share information for this community health assessment, education and awareness was provided to ARHA on the principles of OCAP. OCAP (Ownership, Control, Access and Possession) is a set of principles long advocated by First Nations in Canada. The principles of OCAP apply to research, monitoring and surveillance, surveys, statistics, cultural knowledge and so on. OCAP is broadly concerned with all aspects of information, including its creation and management. Although OCAP originates from a First Nations context, many of the insights and propositions outlined are relevant and applicable to Inuit, Metis and other indigenous peoples internationally (Schnarch, B., 2004) More information about the OCAP principles can be found at www.naho.ca. What we can take from learning about OCAP includes the building of trust, improved communication, meaningful exchange, capacity PG:22CHAPTER2:SOCIALANDECONOMICDETERMINANTSOFHEALTH building and promoting community empowerment to make change. For the community health assessment, we spoke with community members, health staff from 2 First Nation communities, and obtained information through several Aboriginal Health Transition Fund projects (representative of 3 First Nation communities). FirstNationPeople Thereare7FirstNationcommunitiesintheAssiniboineregion: GamblerFirstNation(Ojibway/Cree) KeeseekooweninFirstNation(Ojibway) RollingRiverFirstNation(Ojibway) BirdtailSiouxFirstNation(Dakota) CanupawakpaDakotaNation SiouxValleyDakotaNation WaywayseecappoFirstNation(Ojibway) ThefirstthreecommunitiesareaffiliatedwiththeWestRegionTribalCouncil,while thenextfourareaffiliatedwiththeDakotaOjibwayTribalCouncil. ItisimportanttorecognizethatthereisdiversityamongFirstNationcommunities, andeachcommunityisdistinctintermsoflanguage,people,anddeliveryofhealth services. Through the community health assessment in 2004, it was identified that the health of First Nation people in the Assiniboine region was of concern. High rates of diabetes and lower life expectancy among First Nation people were especially worrisome. Based on information shared thus far by First Nation communities, those same concerns remain. To date, our work together – ARHA and First Nation communities – has come to include a number of partnerships that focus on health promotion. There are two First Nation communities that are part of the Chronic Disease Prevention Initiative in the region. The region has offered and shared training opportunities with First Nation health staff on Diabetes Risk Factor & Complication Assessment, the Get Better Together Chronic Disease management program, suicide prevention, and Mental Health First Aid. The region’s Home Care program has also shared Home Care Skills Enhancement opportunities for communities on request. Dietician services have also been made available in some First Nation communities, as requested. The Assiniboine region is a partner in the annual Diabetes Gathering, which is a one day forum on Type 2 diabetes prevention and awareness. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:23 The Assiniboine Regional Health Authority has been involved in partnerships recently to assist in identifying the strengths and challenges in relation to the health of First Nation and Métis residents of the region. Focus group meetings were held in some Dakota Nation communities and the region has been involved in Aboriginal Health Transition Fund Adaptation and Integration projects with the West Region Tribal Council Health Department. These projects are intended to identify and address gaps in service and access to quality health care in the seven First Nations communities affiliated with the West Region Tribal Council. A multi-jurisdictional committee is conducting a comprehensive health needs assessment, environmental scan and asset mapping of the communities. Following this, the projects plan to implement strategies to close the service gaps identified, improve access, and adapt and integrate services to incorporate First Nations culture and traditional knowledge. According to Health Canada, adaptation refers to the redesign, reorientation or modification of existing provincial/territorial health services and programs to improve both their availability and appropriateness in meeting the health needs of all Aboriginal peoples. Integration refers to efforts to improve coordination and collaboration between the universalhealthsystemsfundedbytheprovincial/territorialgovernmentsandthehealth systemsinFirstNationsandInuitcommunities,fundedbythefederalgovernment. (From:www.hcsc.gc.ca) Respecting the boundaries and affiliations that the 7 First Nation communities in our region have, and recognizing that information did not come from all communities, we did find that that there were similar issues identified across communities and at a Tribal Council level. For these reasons, results will be presented together. PG:24CHAPTER2:SOCIALANDECONOMICDETERMINANTSOFHEALTH Figure2.3FirstNationsRegionalHealthSurveyDeterminantsofHealth FirstNationsRegionalLongitudinalHealthSurvey,2005 A determinants of health framework for First Nations people has been developed through the First Nations Regional Longitudinal Health Survey (RHS). RHS is the only First Nations governed national health survey in Canada. This framework is similar to other frameworks, but also includes a focus on community and personal wellness. A full analysis of the determinants of health for Aboriginal people in the Assiniboine region is beyond the scope of this report, but some of the highlights identified through the community engagement process will be discussed using the four major categories of social economic, health behaviours/lifestyle, physical health, and personal and community wellness and culture. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:25 SocialEconomic The availability of services and benefits for First Nation people is complex to those who are not familiar with the federal system. Jurisdictional differences add to the complexity of health care delivery for First Nation people. Many RHA providers may not be aware of Non-Insured Health Benefits (NIHB), which are health benefits that are provided to registered First Nation people through First Nations and Inuit Health. These include: eye & vision care, dental, medical transportation, medications, medical supplies & equipment, crisis counselling, and approved health services outside of Canada. There are limitations on these benefits and prior approval is often required. Community members spoke often of the limitations of Non-Insured Benefits. One of the biggest concerns for community members was access to primary care providers. Occasionally, people will relocate in order to obtain services. Distance can create barriers to access as transportation is not always readily available. It was suggested that more mobile services or Telehealth options would be beneficial. Community members benefit from discharge planning and follow-up through their local Health Centre. When information is provided to the community health nurse prior to discharge, it is appreciated and improves continuity of care when the client returns home. Medical transportation may be available through NIHB, but the service is in great demand and the vehicle may be already booked when someone needs it. Prior approval is needed for transportation, which creates difficulties when someone receives short notice for an appointment. Not all aspects of travel are covered by NIHB, such as escorts for social support and/or translation. Medication coverage is another concern of community members. Not all medications are included in the approved NIHB list, and it may take some time before the prescription can be filled. If a medication is not covered by NIHB, some people may go without the medication. Medical equipment and supplies may be provided by NIHB, but the amount may be limited, and the delivery may not always be timely. Good communication is essential for providing quality care. It is important that providers explain medical conditions and their causes, and discuss medications and their proper use in a way that people can understand. Because there may be language challenges, particularly for elders, it was suggested that interpreters or translators would be beneficial to assist them when accessing health care. It was also suggested that health care providers need to be aware of the socioeconomic realities of living in First Nation communities. Another crucial component of quality care is establishing trusting relationships with clients and communities. Foremost is treating everyone with respect and fairness, avoiding stereotypical attitudes, and ensuring that those who need care urgently are seen before others with minor complaints. PG:26CHAPTER2:SOCIALANDECONOMICDETERMINANTSOFHEALTH There are a number of programs available for women, but male health programs were seen as lacking. Prostate cancer screening and parenting education for males were considered important. It was felt that men may be more reluctant to admit or discuss health concerns, and may tend to give up if there are long waiting times. People from First Nation communities have said that they are not aware of the services provided by the region, and it would be helpful to know what we offer. It was felt that the lines of communication should be opened between the region and communities so that we can get to know each other better and work together toward things that we can change. Training and education were important to community members, particularly training for local people in the health professions and to provide emergency response. In some situations, it can be difficult for EMS providers to find the location of homes on a reserve, lengthening emergency response time. Training of male health care providers was also considered important so that males could be available to provide personal care to male elders who may not be comfortable with a female caregiver. Community members expressed concern about employment opportunities, income, and housing. Some said that it was difficult to afford to eat a healthy diet and at times to meet basic needs. Lack of employment opportunities and educational requirements for hiring were also concerns. There is a shortage of safe, suitable housing in many communities, leading to overcrowding and health concerns about mould. Many community members expressed the need for elder housing to support the growing need in communities. HealthBehaviours/Lifestyle There is interest in healthy living and learning more about how to improve lifestyles, but there are barriers in some communities. There may not be a local store where people can buy healthy food, or transportation may be a challenge. Meals on Wheels programs are valued programs for elders, but there may not be funding for them. Water quality is an issue in some communities. Community members would like opportunities for recreation like sports and exercise programs, but facilities are not always available. PhysicalHealth Safety is a concern on roads in First Nation communities. Road conditions may be poor, and lack of safety features such as street lights or crosswalks may contribute to injuries. Diabetes remains a major health issue for First Nation people in the region. It was felt that people could benefit from education about diabetes management. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:27 Personal&CommunityWellnessandCulture In order for health care professionals to provide culturally sensitive care, it is important to understand how historical events have influenced the health of Aboriginal people. Colonization, the creation of reserves, and residential schools have had lasting effects on the health and wellbeing of Aboriginal people. The impact of residential schools is still being felt today. Many First Nation and Métis people who attended Indian residential schools experience symptoms similar to those of post-traumatic stress disorder. This constellation of symptoms has come to be known as residential school syndrome (Brasfield, C., 2001). For these reasons, mental health supports are considered important for First Nation people; although communities report that there are not enough of these supports available to meet the needs. More supports for addictions, spiritual health, grief support, and family conflict were considered beneficial. Culture, traditions and languages are very important for First Nations people. The belief shared by most is that their cultural identity, signified by traditions and languages is the source of strength that needs to be protected and promoted. Advancements have been made by incorporating cultural, traditional, and language components into services delivered at community level (e.g. health and education). MétisPeople Thereare11ManitobaMétisFederationLocalsintheAssiniboineregion: AssiniboineLocal(Birtle) SteMadeleineHeritage(Binscarth) CherryCreekMétisCouncil(Boissevain) FortElliceLocal(St.Lazare) LesMétisLocal(Minnedosa) PellyTrailLocal(Russell) PembinaRiverLocal(SwanLake/Belmont) RiversLocal(Rivers) SnakeCreekLocal(Birtle) TurtleMountainLocal(LakeMetigoshe) WapitiLocal(Onanole) Another Aboriginal Health Transition Fund (AHTF) Adaptation project the Assiniboine region has been invited to join is a Manitoba Métis Federation (MMF) Knowledge Network Project through the Southwest Region Health & Wellness Department. The MMF Adaptation project has allowed the implementation of MMF Region/RHA PG:28CHAPTER2:SOCIALANDECONOMICDETERMINANTSOFHEALTH Knowledge Networks to interpret outcomes of a study of Métis health status and health services utilization and establish priority adaptation options in regions. The Southwest Knowledge Network is gathering information from members of the Métis community and the Assiniboine region will participate in the Knowledge Network when the data from a new study on the health of Métis people in Manitoba is released. This information was not available for inclusion in the CHA report at the time of printing. In the past we heard that some of the health concerns of Métis people were similar to those of other residents of the Assiniboine region: awareness of services that are available, availability of health care services, lack of transportation to access care, awareness of how to live a healthy life, and affordability of services that are not covered by the provincial health care system. Residents from the Métis community felt that rural people are disadvantaged due to distance. There was interest from community members to learn more about the unique health needs of Métis people. Historical events have also affected the Métis people of the region and levels of trust. Many Métis people attended residential schools and there is ongoing controversy about scrip and land acquisition. Métis people are not eligible for the benefits that are available to registered First Nation residents. The Regional Coordinator Aboriginal Health provides the program and communication link between the Assiniboine RHA, Aboriginal groups, and First Nations communities. Key to the position is responsibility for the coordination and consultation around the development, implementation, and monitoring of a regional Aboriginal-specific health work plan that includes: relationships and partnerships, health promotion, regional programs and services integration, cultural competency within ARHA, representative workforce strategies, and capacity building. There are a number of initiatives that are currently being worked on, such as the Aboriginal Human Resource Initiative through the Representative Workforce Strategy. Networking has included a variety of partners, most recently Fist Nation and Inuit Health. When there is sharing at various levels, it enhances the opportunity to make positive change. HutterianandOldOrderMennonite There are 28 Hutterite Brethren colonies in the Assiniboine Region, with the majority being located in the eastern half of the region. While it is not possible to provide an accurate count of how many people of Hutterian background live in the region, this is a significant population group that we serve. We are grateful for the opportunity to speak with people in these communities so that we may reflect their views in this report. People from seven colonies were interviewed for the CHA. As with all communities, each colony is unique. It was felt that there is a large support network of people and stable family environments in these communities. Other positive ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:29 aspects included working together and role models. Areas for improvement varied among communities. There was interest in education and access to information about health and diseases, healthy eating, and more physical activity. Healthy living “challenges” were discussed as ways of improving the health of community members. There is a settlement of Old Order Mennonite people to the northeast of the region who access health services from Neepawa. This is a strong spiritual community, living a traditional way of life. There is a great deal of physical labour and each family produces its own food. Birth rates tend to be high in the community, although it was felt that economic conditions may lead to smaller families in the future. This population does not have Manitoba Health cards, instead opting to pay for services as needed. The community identified cardiovascular disease, strokes and gastrointestinal ailments as concerns. There is limited access to technology and communication. We appreciate the opportunity to discuss health and health care with them. Internal/ExternalMigration Internal migrants are people that lived in a different Canadian municipality one year prior to the Statistics Canada Census in question. The region has a relatively low rate of internal migration compared to most other rural RHAs but is comparable to Manitoba as a whole which is heavily influenced by the low rate in Winnipeg. External migrants are people that lived outside of Canada one year prior to the Census in question. The region’s rate of external migration increased noticeably between 1996 and 2001 from 0.2% to 0.5% (approximately 340 individuals) but dropped back to 0.3% at the 2006 Census. Table2.1Internal/ExternalMigration1996,2001and2006Censuses Manitoba Burntwood NorMan Churchill Parkland N.Eastman Interlake Winnipeg Brandon Assiniboine Central S.Eastman 1996 4% 6% 8% 10% 6% 6% 6% 3% 8% 5% 5% 7% InternalMigration 2001 2006 4% 4% 6% 4% 5% 5% 14% 2% 5% 6% 5% 6% 6% 6% 3% 2% 7% 7% 4% 4% 5% 6% 6% 7% 1996 0.5% 0.0% 0.2% 0.0% 0.1% 0.2% 0.1% 0.7% 0.2% 0.2% 0.4% 0.7% ExternalMigration 2001 0.7% 0.1% 0.2% 0.0% 0.2% 0.3% 0.3% 0.8% 0.4% 0.5% 0.9% 1.1% 2006 0.9% 0.1% 0.3% 0.0% 0.1% 0.5% 0.2% 1.2% 0.9% 0.3% 0.9% 0.8% SOURCE:STATISTICSCANADACENSUSES1996,2001and2006 PG:30CHAPTER2:SOCIALANDECONOMICDETERMINANTSOFHEALTH Immigrants Since the latest Census, there has been an increase again in immigration from other countries. Certain communities in the region have experienced increases in immigration in recent years from Germany, Ukraine, Korea, and the Philippines. We spoke with immigration services, new immigrants, and some of their employers. New immigrants state that they experience social isolation for a number of reasons. Some may have had to leave loved ones behind to come to Canada. They may feel isolated due to lack of transportation to larger centres such as Winnipeg or Brandon where they can meet with people of similar ethnic background. There are concerns about integration into rural communities, with parents worrying whether their children will be accepted by others at school. Families appreciate the many opportunities Canada holds for them and their children. Through a student project by T. Slimmon in the Assiniboine region in 2008, health care providers identified the following supports as beneficial for immigrant families: assistance to get to know and adjust to the community, information about living in Canada: work, licenses, health system, education system, work force issues, laws, weather, food, the rights they have living in Canada; access to used clothing & furniture, health care service availability, affordable housing, community organizations and events, English as an Additional Language classes, and resources in their own language. Many new immigrants indicate that they have difficulty navigating the health care system. It can be a challenge for health care providers here to obtain previous medical records and immunization status from other countries. It was noted that some new immigrants have unusual allergies that typically aren’t seen among residents here, such as oranges, honey, and cinnamon. Language has been identified as a barrier to accessing health services for new immigrant families. Improved access to translators may be beneficial to this population. Some immigrant families may use friends and neighbours to assist with translation when accessing health care, although it may be disconcerting when discussing personal health information. It was suggested that it would be helpful for health care providers to have dictionaries available (e.g. English-German, English-Korean) to assist with translation. There are a number of immigrants from the United Kingdom and Europe in the Assiniboine region. Immigrants who are English-speaking may have fewer challenges navigating the health care system and establishing connections in the community. Internal migrant mobility is a measure of the number of people that lived in a different Canadian municipality at the time of the previous Census (5-year mobility). The region’s five year mobility has been slightly higher than that of Manitoba as a whole in the last three census periods. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:31 In recent years, a large number of people had moved west to Alberta to seek employment when jobs there were plentiful. Since the economic downturn, more people are returning to Manitoba. The oil industry in the south western portion of the Assiniboine region has attracted workers to the area. Table2.25YearInternalMigrantMobility1996,2001and2006Censuses Manitoba Assiniboine 5YearInternalMigrantMobility 1996Census 2001Census 2006Census 12% 12% 11% 15% 14% 13% SOURCE:STATISTICSCANADACENSUS1996,2001AND2006 LanguagesSpokenintheHome The language spoken most often or on a regular basis at home is recorded as part of the Statistics Canada Census. In the Assiniboine region more than 92% of the time, that language is English with less than one percent French and just under one percent recorded as another ‘unofficial’ language. Almost 4% reported that they speak English and another unofficial language in the home. Table2.3LanguagesSpokenIntheHome1996,2001and2006Censuses 1996Census 2001Census 2006Census English French 93.6% 90.6% 92.1% 0.7% 0.4% 0.8% Other (unofficial) 4.9% 1.4% 0.7% EnglishAnd French 0.1% 1.0% 0.0% EnglishAnd Other 0.7% 6.4% 3.9% SOURCE:STATISTICSCANADACENSUS1996,2001,2006 A number of residents report speaking English and another unofficial language in the home. This reflects comments from community and staff who report that there is a growing need for classes in English as an Additional Language. Schools report increasing numbers of students who do not speak English as their first language. While a small percentage of residents report speaking French in the home, the Assiniboine Region is a designated bilingual region. A French Language Services plan was developed in 2009 in consultation with Francophone residents. Since then, a focus group was held in the community of St. Lazare to provide an opportunity for Francophone residents to provide their perspective on health in the community. Many of the ideas expressed at the focus group were similar to those of residents from other communities, particularly those related to access to services. There were, however, some issues specific to the Francophone community. PG:32CHAPTER2:SOCIALANDECONOMICDETERMINANTSOFHEALTH Having a French language (Division Scholaire Franco-Manitobaine) school in the community was seen as beneficial to building strong community ties and in retaining young people in the community. The participants felt that there was a strong sense of community in and around St. Lazare, which was described as a place where people help one another. The community members indicated that they were a French-speaking community but believed there was “no Francophone representation at the RHA.” It was mentioned that it would be good to have reception services at Birtle hospital available in French, although participants also recognized that it is “not easy to recruit in small communities and even more difficult to recruit for a bilingual position.” Urban/RuralPopulation An Urban area is defined by Statistics Canada as having a minimum population of 1,000 and a population density of 400 people per square kilometre. The population of the Assiniboine RHA is predominantly rural (71%) and this is one of the community characteristics that allows us to compare ourselves with other similar regions (peer groups) As can be seen from below, the region with the closest Urban/Rural population split to us is South Eastman. This of course is not the entire story as South Eastman has a considerably higher population density than our region at 6.15 per square kilometre compared to 1.94 for our region. The Assiniboine RHAs population density has dropped steadily along with its population from 2.04 per sq. km at the 1996 Census to 1.94 at the 2006 Census. Table2.4Urban/RuralPopulationSplit1996and2001Censuses Canada Manitoba Burntwood NorMan Parkland N.Eastman Interlake Winnipeg Brandon Assiniboine Central S.Eastman 1996Census Urban Rural 77.9% 22.1% 71.8% 28.2% 40.0% 60.0% 60.5% 39.5% 35.4% 64.6% 14.5% 85.5% 24.5% 75.5% 98.9% 1.1% 88.2% 11.8% 27.9% 72.1% 35.9% 64.1% 25.2% 74.8% 2001Census Urban Rural 79.6% 20.4% 71.7% 28.3% 33.8% 66.2% 58.2% 41.8% 35.6% 64.4% 18.5% 81.5% 21.8% 78.2% 99.3% 0.7% 88.2% 11.8% 28.6% 71.4% 36.0% 64.0% 27.3% 72.7% SOURCE:STATISTICSCANADACENSUS1996,AND2001 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:33 CommunityDevelopment There appears to be consensus that growing, vibrant communities are healthy communities. Community members, staff, and partners are concerned about rural depopulation and the effect of shrinking populations on the economy, services, and social capital in our communities. Many rural communities have experienced a decline in businesses and services in recent decades. During the Community Engagement meetings, there was much discussion about initiatives and ideas to attract and retain residents to our communities. There was particular emphasis on attracting young people, health care providers, and businesses to our communities. People recognize the importance of supporting and building upon existing resources in our communities. Many municipal leaders, service groups, and faith-based organizations are building capital for residents and communities through economic development, improvement of recreation facilities, and creation of supports such as food banks and thrift shops. It was suggested that communities can support people to make healthy choices in their design and through community spirit and involvement. Education Education attainment is widely acknowledged as a key component of socioecomic status and is positively associated with health. It is an important characteristic in health service planning and delivery. The lack of a high school diploma remains a significant predictor of negative outcomes: lower earnings, higher rates of unemployment, poorer health, higher rates of reliance on social assistance, and higher rates of teen motherhood. LevelofEducation The highest level of education amongst residents of the ARHA is comparable to that in the majority of rural regional health authorities. It is however significantly lower than that of the two major urban areas; Winnipeg and Brandon, particularly in the percentage of residents with less than high school education. The highest education level falls with age and is particularly noticeable in those residents aged 65 and over with fully 57% of them having less than high school education compared to 46% in Manitoba as a whole. PG:34CHAPTER2:SOCIALANDECONOMICDETERMINANTSOFHEALTH Figure 2.4 Residents (Aged 15+) with less than a high school education at 2006 Census Residentswithlessthanhighschooleducation MBAvg SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood Manitoba 0% 10% 20% 30% 40% 50% 60% SOURCE:STATISTICSCANADACENSUS2006 Table2.5HighestEducationLevelsat2006Censusbyagegroup Nocertificate/ diplomaordegree HighSchool Apprentice/Trade certificate Other–Non University University 1524 AssiniboineRHA 2564 65+ 1524 Manitoba 2564 65+ 59% 26% 57% 48% 20% 46% 28% 28% 18% 36% 25% 21% 3% 13% 10% 3% 11% 11% 6% 18% 8% 6% 19% 10% 5% 16% 7% 7% 24% 12% SOURCE:STATISTICSCANADACENSUS2006 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:35 A breakdown of education level by the six ARHA districts shows no significant differences in any particular district at any age. A gender breakdown of the ‘highest level of education’ amongst the residents of the ARHA at the 2006 census shows a slightly higher level of education amongst females. This is particularly noticeable in the number of residents with no certificate, diploma, or degree with 42% of males in this category and only 35% of females. This disparity increases with age from being almost nothing in the 15-24 age group to 10.9% in the 65 and over age group and is not something that is reflected in Manitoba as a whole. Figure2.5HighestLevelofEducationbyGender2006(Aged15+) MaleARHA FemaleARHA 42% Nocertificate,diploma,or degree 35% 25% Highschoolcertificateor equivalent 26% 12% Apprenticeshiportrades certificateordiploma 9% College,CEGEP,orother nonuniversitycertificateor diploma 11% 17% Universitycertificateor diplomabelowthe bachelorlevel 4% 5% 7% Universitycertificate, diploma,ordegree 9% 0% 10% 20% 30% 40% 50% SOURCE:STATISTICSCANADACENSUS2006 Through information obtained from partners, providers, and communities, it was discovered that there are concerns in the region about basic literacy. Literacy is an important determinant of health, contributing to social and economic conditions. Low literacy in some population groups can contribute to health disparities. Basic literacy is essential to performing daily activities such as grocery shopping and managing personal finances. PG:36CHAPTER2:SOCIALANDECONOMICDETERMINANTSOFHEALTH Health literacy is the ability to understand information about what contributes to health, how to access health services, and how to interact with health care providers. Improvements in health literacy can lead to better health for our residents. Plain language health education material and using various formats for health promotion messaging, such as video recordings and pictorial information, can increase accessibility of health information. Communities also mentioned the importance of culturally appropriate material and messaging about health. SchoolReadiness ‘Readiness for school’ is a baseline of children’s readiness to begin grade one. As children’s readiness for school is influenced by their early years – and the family and community factors that shape children’s early years – Early Development Instrument (EDI) results are a reflection of the strengths and needs of children’s communities The EDI is an annual questionnaire measuring Kindergarten children's ‘readiness for school’ across several areas of child development; physical health and well-being, social competency, emotional maturity, language and thinking skills, and communication skills and general knowledge. EDI results assist communities in planning for the services and programs children need in order to learn and enjoy their school experience. More information on the EDI in Manitoba can be found at www.gov.mb.ca/healthychild/edi/index.html EDI results for the Assiniboine RHA are reported as North and South in line with the region’s two Parent Child Coalitions. The average EDI scores for 2005-2006 and 20062007 for our region and Manitoba can be seen below with 10 being the best possible score. Table2.6AverageEDIscores2005/20062006/2007 Physicalhealth andwellbeing Social competence Emotional Maturity Languageand thinkingskills Communication andgeneral knowledge ARHA NORTH 20052006 ARHA SOUTH 20062007 ARHA SOUTH MANITOBA MANITOBA ARHA NORTH 9.13 8.84 8.75 9.07 9.02 8.78 8.63 8.57 8.32 8.45 8.63 8.36 8.19 8.25 7.94 8.06 8.16 7.97 8.53 8.39 8.11 8.45 8.65 8.21 8.25 7.79 7.57 8.21 7.83 7.64 SOURCE:HEALTHYCHILDMANITOBAEDIREPORTS20052007 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:37 In general for the two year period, EDI scores in the region are consistently higher in all categories than in Manitoba as a whole. Scores in 2005-2006 were significantly higher in the North of the region, but have since moderated and are comparable with those in the South for 2006-2007. Using percentile rankings, there is an expectation that 30% of EDI scores should fall within the ‘very ready’ category in each of the five areas of development. More than 30% indicates strength in that area of development. The following table details the percent of children who were ‘very ready’ for school compared to that in the rest of Manitoba. Table2.7Percentofchildrenwhowere‘veryready’forschool2005/20062006/2007 Physicalhealth andwellbeing Social competence Emotional Maturity Languageand thinkingskills Communication andgeneral knowledge Oneormore areas Twoormore areas ARHA NORTH 20052006 ARHA SOUTH ARHA NORTH 20062007 ARHA SOUTH MANITOBA MANITOBA 41.2 31.4 32.1 41.2 36.5 33.6 36.1 40.1 33.9 35.1 37.8 34.8 27.4 37.2 28.2 29.8 28.6 28.5 36.5 36.8 30.0 36.5 35.5 32.5 38.7 36.1 33.9 36.7 36.5 36.0 64.2 67.9 62.4 64.9 68.8 64.8 48.6 52.0 43.3 47.9 48.7 45.5 SOURCE:HEALTHYCHILDMANITOBAEDIREPORTS20052007 In general, for 2006-2007, the percent of children who were ‘very ready’ for school in the region (in the individual areas) compares very well with the rest of Manitoba, particularly in the ‘physical health and well-being’ area. Emotional maturity (in common with the rest of Manitoba) is the only area of where ‘strength’ is not indicated. Similarly, there is an expectation that 10% of scores should fall within the ‘not ready’ category in each of the five areas of development. More than 10% would indicate a ‘need’ in that area. The following table details the percent of children who were ‘not ready’ for school compared to that in the rest of Manitoba. PG:38CHAPTER2:SOCIALANDECONOMICDETERMINANTSOFHEALTH Table2.8Percentofchildrenwhowere‘notready’forschool2005/20062006/2007 Physicalhealth andwellbeing Social competence Emotional Maturity Languageand thinkingskills Communication andgeneral knowledge Oneormore areas Twoormore areas ARHA NORTH 20052006 ARHA SOUTH 20062007 ARHA SOUTH MANITOBA MANITOBA ARHA NORTH 6.1 11.2 11.3 7.0 7.6 10.9 4.5 7.2 9.9 7.3 5.3 9.6 4.8 7.6 10.6 7.1 6.6 10.1 9.3 9.7 12.5 9.6 4.6 11.8 5.8 10.1 11.1 4.8 9.9 11.0 18.8 21.7 28.3 19.8 21.1 27.7 7.7 11.9 14.6 9.3 7.9 13.9 SOURCE:HEALTHYCHILDMANITOBAEDIREPORTS20052007 The region again compares very well with the rest of Manitoba with no specific areas where ‘needs’ are identified. However, ‘language and thinking skills’ in the North and ‘communication and general knowledge’ in the South are the areas identified as requiring the most attention. In 2006-2007, 651 kindergarten children from 60 schools participated in the study across the region compared to 637 from 52 schools in 2005-2006. Some general information is outlined below. Table2.9GeneralinformationonARHAkindergartenchildren. PercentageofparticipatingchildrenwithEnglish asasecondlanguage PercentageofparticipatingchildrenwithFrench asasecondlanguage Percentageofparticipatingchildrenwithspecial needs Percentageofchildrenparticipatingwhorequire furtherassessmentconcerningpossiblespecial needs 20052006 20062007 5.2% 8.0% 0.8% 2.0% 3.1% 3.5% 9.1% 11.1% SOURCE:HEALTHYCHILDMANITOBAEDIREPORTS20052007 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:39 From 2005-2006 to 2006-2007 there have been significant increases in the percentage of kindergarten children where either English or French is a second language as well as the percentage of children who require further assessment concerning possible special needs. During the community health assessment, school staff with knowledge of special needs and guidance were consulted. There was general agreement that there are more students starting school without the basic skills for learning and greater numbers of students with special needs in our schools. It was also noted that in recent years there are more students in schools with behavioural issues. School staff indicate that there are increasingly complex needs among children coming to school, and it can be a challenge to maintain the skill sets necessary to address these needs. While there are programs in place that were developed to assess child development and enhance children’s readiness to learn, providers in the school system indicate that these services may not necessarily be translating into improved school readiness. It is important for developmental delays to be identified early in order to optimize outcomes. Some developmental delays which may not be picked up prior to school entry include anxiety/attachment disorders, as well as vision and dental issues in the early years. Some health care providers who work with children and youth discussed the acceleration in concepts taught in schools. These providers felt that children are learning more at an earlier age now and the expectations for learning have increased over the years. There are a lot of societal expectations placed on the school system, with school settings viewed as an ideal place to convey social and health promotion messages to students. Schools do their best to accommodate these types of requests within their capacity. It is being increasingly recognized that healthy child development is ideally a shared responsibility, with the best outcomes achieved when there are partnerships among families, schools, and communities. SchoolChanges Frequent school moves are associated with a higher rate of grade retention (the requirement for a student to repeat a grade) which in turn is associated with higher rates of subsequent school failure and high school withdrawal. The Assiniboine region has the highest percentage of Grade 3 students with no school changes in 4 years in the province at 90.2% for both of the cohorts studied. This is reflected in the region’s high school completion rate which is also the highest in the province at 82.1% for the 2002/03 school year and 86.1% for the 2005/06 school year. PG:40CHAPTER2:SOCIALANDECONOMICDETERMINANTSOFHEALTH Figure2.6Grade3SchoolStudentswithNoSchoolChangesin4Years1997/98 2000/01and2002/032005/06(SexAdjusted) 1997/982000/01 2002/032005/06 MBAvg1997/982000/01 MBAvg2002/032005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood South Mid North Manitoba 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% SOURCE:MCHPCHILDHEALTHATLAS2008 Income Income is considered to be one of the most important determinants of health. As income and social status increase, overall health status also tends to improve. Therefore, higher income earners tend to be healthier than people with lower incomes. Populations with a more equal distribution of income also tend to be healthier than those in which there is a greater income spread between the rich and the poor. Income is often influenced by the level of education achieved. Community members, partners, and staff are concerned about the economy and poverty, reporting increased use of food banks, and limited access to recreation opportunities for lower income families. School staff have stated that there is a growing disparity between the families who are well off and those who are not. There was general agreement that income greatly affects quality of life. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:41 IndividualIncome The median individual income (the individual income value which divides the individual income distribution into two halves, i.e. the incomes of one half of individuals are below the median value, while those of the other half are above the median) of the region is considerably lower than that of Manitoba as a whole at $17,635 for females and $23,968 for males compared to the Manitoba values of $20,169 for females and $29,919 for males at the 2006 Census. The disparity is highest amongst males with the median income of Manitoban males being 1.25 that of males in the Assiniboine region at the 2006 census. Figure2.7MedianIndividualIncome2001and2006Censuses 2006CensusMale 2006CensusFemale MBFemaleAvg MBMaleAvg SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood Manitoba $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 SOURCE:STATISTICSCANADACENSUS2001AND2006 PG:42CHAPTER2:SOCIALANDECONOMICDETERMINANTSOFHEALTH Median individual income level varies considerably across the districts of the region with North 1 having the lowest median income for males, and along with West 2 the lowest median income for females. The highest median income levels for both males and females can be found in East 1. The difference between males and females in the region is less pronounced than that of Manitoba as a whole with female median income for the region being 0.74 that of males compared to 0.67 in Manitoba at the 2006 Census. Table2.10MedianIndividualIncome2001and2006Censuses(DistrictandRHA) East2 West1 North1 West2 East1 North2 Assiniboine Manitoba 2001Census Female $15,471 $14,776 $14,004 $13,825 $15,514 $14,666 $14,700 $16,602 Male $20,431 $22,168 $18,794 $20,130 $23,066 $18,761 $20,330 $26,265 2006Census Female $17,807 $18,823 $16,763 $16,666 $18,587 $18,362 $17,635 $20,169 Male $25,557 $23,875 $19,824 $25,191 $26,002 $22,911 $23,968 $29,919 2006Census ARHA/MBRatio Female Male 0.88 0.85 0.93 0.80 0.83 0.66 0.83 0.84 0.92 0.87 0.91 0.77 0.87 0.80 SOURCE:STATISTICSCANADACENSUS2001AND2006 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:43 HouseholdIncome The median household income (the household income value which divides the household income distribution into two halves, i.e. the incomes of one half of households are below the median value, while those of the other are above the median) of the region is considerably lower than that of Manitoba as a whole at $38,171 at the 2006 Census compared to $47,875 for Manitoba. Figure2.8MedianHouseholdIncome2001and2006Censuses 2006Census 2001Census MB2006 MB2001 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill Norman Burntwood Manitoba $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 $55,000 $60,000 SOURCE:STATISTICSCANADACENSUS2001AND2006 Median household income level varies across the districts of the region but as with individual income, North 1 has the lowest median income and East 1 the highest, with very little change in any district between the two Census periods. PG:44CHAPTER2:SOCIALANDECONOMICDETERMINANTSOFHEALTH Table2.11MedianHouseholdIncome2001and2006Censuses(DistrictandRHA) 2001Census 2006Census $34,264 $34,252 $30,150 $31,953 $35,307 $32,183 $32,651 $41,661 $39,909 $37,466 $34,528 $39,061 $40,008 $36,937 $38,171 $47,875 East2 West1 North1 West2 East1 North2 Assiniboine Manitoba 2001Census 2006Census ARHA/MBRatio ARHA/MBRatio 0.82 0.83 0.82 0.78 0.72 0.72 0.77 0.82 0.85 0.84 0.77 0.77 0.78 0.80 SOURCE:STATISTICSCANADACENSUS2001AND2006 LowIncome(Prevalence) The prevalence of low income is a measure of the percentage of residents (in specific groups) whose income falls below the Statistics Canada LICO-AT (Low income after-tax cut-offs). These are measures of low income differentiated by size of family and area of residence, where families spend disproportionate amounts (twenty percent more than the average family) of their after-tax income on food, shelter and clothing. Low income prevalence rates in the region are relatively low compared to Manitoba as a whole which are heavily influenced by the urban centre of Winnipeg where the cost of living is substantially higher. Table2.12LowIncomePrevalenceat2006Census(DistrictandRHA) East2 West1 North1 West2 East1 North2 Assiniboine Manitoba Economic Families 8% 10% 10% 9% 10% 6% 9% 12% Unattached Individuals 26% 26% 25% 23% 34% 26% 27% 38% Private Households 11% 14% 14% 12% 13% 9% 12% 17% SOURCE:STATISTICSCANADACENSUS2001AND2006 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:45 Low income prevalence does not vary to any substantial degree across the districts of the region as might be expected. People who work with seniors indicate that some of the seniors in the Assiniboine region experience financial difficulties. Many are on a fixed income and those who are living alone may encounter particular hardship. There was also concern about the quality of life for people earning minimum wage. The Community Volunteer Income Tax program (CVITP) is a partnership of Assiniboine Regional Health Authority (ARHA) with the Canada Revenue Agency (CRA). This free program assists people who cannot afford to pay to have their taxes completed and as a result, obtain income they would not otherwise receive. Completing a tax return is needed in order to qualify for many government funded programs, including the Child Tax Benefit and the GST rebate. Through the CVIT program, the CRA trains volunteers to help low income individuals and families complete their tax returns. Completing a tax return is needed in order to qualify for many government funded programs, including the Child Tax Benefit and the GST rebate. Because income is one of the most important determinants of health, the ARHA supports a health promotion coordinator to facilitate the CVITP. As of February, 2010, the following ARHA communities are offering the CVITP: Carberry, Neepawa, Minnedosa, Virden, Rivers, Souris, Russell and Reston. Employment Meaningful employment and job security are important factors that influence health. Employees in major workplaces across the region said that it was important for people to feel that their work matters and that they are contributing to society through the work they do. Community members, including youth, mentioned the need for jobs for young people in our communities and the significance of stable employment. Unemployment has been consistently linked to poor health and has been associated with higher mortality rates, especially from heart disease and suicide. Women who are unemployed have higher rates of anxiety and depression and lower self rated health status. The unemployment rate in the region is amongst the lowest in the province at just 3.8% for females and 3.7% for males at the 2006 Census compared to the Manitoba averages of 10.5% and 5.5% for females and males respectively. In the past, many people travelled west to Alberta for seasonal work and higher rates of pay. More recently, people have been returning to the region because of layoffs and housing shortages out west, and the creation of more jobs with industries closer to home. PG:46CHAPTER2:SOCIALANDECONOMICDETERMINANTSOFHEALTH Figure2.9Unemploymentrate(MaleandFemale)2006Census 2006CensusMale 2006CensusFemale MBFemaleAvg MBMaleAvg SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood Manitoba 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% SOURCE:STATISTICSCANADACENSUS2006 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:47 YouthEmployment The youth unemployment rate (labour force aged 15-24) follows a similar pattern with regional rates of just 7.7% for females and 8.5% for males at the 2006 Census compared to province wide values of 10.5% for females and 11.7% for males. In youth unemployment there are some district level variations with higher rates of unemployment in the West 2 and North 1 districts for both males and females. Table2.13YouthUnemploymentRate(1524)2001and2006Censuses(Districtand RHA) East2 West1 North1 West2 East1 North2 Assiniboine Manitoba 2001Census Female Male 8.3% 7.7% 7.9% 8.8% 19.3% 13.9% 14.7% 12.8% 4.2% 2.6% 6.8% 14.1% 11.0% 11.0% 11.0% 12.0% 2006Census Female Male 7.5% 7.2% 5.5% 9.8% 11.1% 10.2% 12.3% 11.4% 2.4% 5.0% 4.9% 6.9% 7.7% 8.5% 10.5% 11.7% SOURCE:STATISTICSCANADACENSUS2001AND2006 PhysicalEnvironments The natural environment was mentioned by community, staff, partners, and youth as an important factor that influences our health. Access to clean air and water were of particular concern. Some people mentioned worries about the effects of emissions, chemical inputs, and exposure to potentially harmful substances. Community members, and especially youth, mentioned the significance of recycling as it relates to health. People are becoming more aware of the impact of what we use and how we dispose of it. During the community engagement process, one group discussed sustainable development by saying that we need to make “progress while maintaining values and not harming but improving the environment.” Access to safe, suitable shelter is both a basic human need and a determinant of health. Adequacy of housing can have a profound effect on health. Housing benefits may be available for people diagnosed with a mental health condition. The social costs of unaffordable housing are wide-ranging and pervasive. The importance of decent, affordable housing to people’s health and well-being is undisputed. Inadequate housing and overcrowding often contribute to illness, and may lead to increased use of PG:48CHAPTER2:SOCIALANDECONOMICDETERMINANTSOFHEALTH the health care system. Affordable housing is also essential for attracting and retaining a skilled workforce to the region, one of the prerequisites of a robust local economy. HousingAffordablity The percentage of tenants and owners who reported spending more than 30% of their income on housing at each of the 2001 and 2006 censuses is detailed below. The number of home owners in this category has remained relatively stable at around 9-10% which is similar to the Manitoba average and does not vary substantially across the region. Table2.14HousingAffordabilitybyDistrictandRHA2001and2006Censuses East2 West1 North1 West2 East1 North2 Assiniboine Manitoba Tenantspending30%ormore ofincomeonshelter 2001 2006 20% 36% 36% 27% 25% 21% 26% 28% 32% 27% 34% 22% 29% 27% 37% 35% Ownerspending30%or moreofincomeonshelter 2001 2006 9% 10% 10% 9% 9% 9% 12% 9% 10% 10% 10% 11% 10% 9% 11% 11% SOURCE:STATISTICSCANADACENSUSES2001AND2006 The number of tenants spending 30% or more on shelter has also remained relatively stable, dropping from 29% at the 2001 Census to 27% at the 2006 Census. This is considerably lower than the Manitoba rate of 35% which is heavily influenced by the high rental costs in Winnipeg. Community and partners often identified the availability of suitable, affordable housing as a need in communities. It was mentioned that certain groups may have difficulty obtaining safe and suitable housing, such as youth, the elderly, new immigrants, and mental health clients. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:49 Transportation Community members and staff reported many challenges with transportation. Many of these challenges related to access to health care services, while others reflected daily activities and accessing basic necessities. The elderly, families with young children, and those living in remote communities may be more likely to experience issues related to transportation. Service workers in the community indicate that sometimes clients are not able to access services or have their needs met due to lack of transportation to physician clinics, community health appointments, prenatal care, hospitals, and rural services. It is believed that transportation can be a barrier to accessing specialists for some Assiniboine residents, since most specialists only practice in Winnipeg or Brandon. Telehealth is a provincial system for accessing a health care provider through a video link in a designated facility. This may be an option for residents to see some specialists, but it may not always be available or appropriate depending on the situation and specialty. The Telehealth system has been a valuable resource for reducing travel for residents diagnosed with cancer. Handivans are considered important resources for the community. The cost of operating and maintaining them in some communities has become a burden. At times, seniors may not use a Handivan service if they feel they cannot afford the cost. Some communities who rely on volunteers are finding it difficult to maintain an adequate number of drivers. There are approximately twenty five community-owned Handi-Vans in operation in various communities in Assiniboine. Community members felt that access to transportation was essential in rural communities for minimizing isolation and remaining socially engaged. This was considered especially important for the elderly. There are some programs which provide volunteer drivers for seniors, but it is becoming more difficult to find people who have the time and willingness to volunteer. Youth may also have transportation challenges when seeking health services and recreation opportunities. Sometimes youth may not be able to find transportation to access services, especially after school hours. In some cases, youth may prefer to seek services in other communities in order to maintain anonymity. PG:50CHAPTER2:SOCIALANDECONOMICDETERMINANTSOFHEALTH SocialSupports Social support and good social relations make an important contribution to health. Social support helps give people the emotional and practical resources they need. Belonging to a social network of communication and mutual obligation makes people feel cared for, loved, esteemed, and valued. This has a powerful protective effect on health. Supportive relationships may also encourage healthier behaviour patterns. Support operates on the levels both of the individual and of society. Social isolation and exclusion are associated with increased rates of premature death and poorer chances of survival after a heart attack. People who have less social and emotional support from others are more likely to experience less well-being, more depression, a greater risk of pregnancy complications, and higher levels of disability from chronic diseases. In addition, negative personal relationships can lead to poor mental and physical health. A random sample of Assiniboine residents were asked in a telephone survey if they have someone who can listen to them when they feel anxious or upset. Of those who responded, 6% said they did not have anyone. There were no significant differences between men and women, but 7% of males and 5% of females responded that they did not have anyone to listen to them. (Assiniboine Regional Health Authority, 2009) In the same survey, people were asked if they felt part of the community in which they live. The vast majority of people (92%) said they felt part of their community. Youth mentioned the prevalence of bullying in schools and the community. Many schools have implemented anti-bullying initiatives, but this remains a pervasive issue. Students were asked through the Youth Health Survey if they felt safe in their schools. Of the students who responded to this question, 84% said that they did. Students who feel connected to their schools tend to have better academic performance and are less likely to smoke or engage in other risky or unhealthy behaviours. When asked if they feel close to people at their school, 79% of students said yes; and 81% responded that they feel they are a part of their school. There was concern from community members about isolation and loneliness among seniors. Some community partners indicated that many seniors do not have the support of family as younger generations become busier with their own children or move elsewhere. There are resources that assist seniors and provide activities, such as Support Services to Seniors programs. These programs are described in more detail in chapter 9. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:51 Many people, including youth, stated that they valued daily interaction and would like to see more intergenerational activities in our communities. There are numerous benefits to intergenerational activities, such as helping young people to learn new ideas and skills, giving young people something to do in their communities, and reducing isolation among seniors. Employees of major workplaces in the region discussed the value of social support networks among co-workers. Workplaces were identified as venues for health promotion by encouraging and supporting healthy lunch choices and physical activity opportunities for employees. Volunteerism is an important part of rural life. Many organizations and activities would not exist without the commitment of volunteers. Community members spoke of the declining numbers of people willing or able to volunteer, with the same people often participating on the various committees in the community. In the Adult Health Survey, which was conducted in 14 communities across the region, 58% of people said that they volunteer for local groups. Females (61%) were more likely than men (54%) to say that they were a volunteer in their community. When asked if they had attended a community event in the past 6 months, 86% of females and 77% of males stated that they had. MaritalStatus The marital status of residents aged fifteen and over in the Assiniboine region is detailed below with around 26% single, 58% married, and the rest either separated, divorced, or widowed. The region had a higher rate of marriage and lower rate of divorce or separation than Manitoba as a whole at the 2006 Census. Table2.15MaritalStatusesat2006Census Assiniboine Manitoba Single 25.7% 33.3% Married 58.4% 50.2% Separated 2.0% 2.8% Divorced 5.4% 6.8% Widowed 8.5% 6.9% SOURCE:STATISTICSCANADACENSUS2006 PG:52CHAPTER2:SOCIALANDECONOMICDETERMINANTSOFHEALTH LoneParentFamilies In comparison to the rest of Manitoba the region has a relatively low percentage of lone parent families, the vast majority of which (in line with all of Manitoba) are headed by females. Figure2.10PercentageofLoneParentFamilies2006Census FemaleLoneParentFamilies 6.3% SouthEastman MaleLoneParentFamilies 2.3% Central 8.1% Assiniboine 7.9% 2.7% 2.2% 12.2% Brandon 2.3% 3.3% 15.9% Winnipeg 3.1% 10.9% Interlake 9.5% NorthEastman 3.1% 13.4% Parkland 3.2% 18.5% Norman 5.4% 22.1% Burntwood 13.7% Manitoba 0% 5% 7.9% 3.3% 10% 15% 20% 25% 30% SOURCE:STATISTICSCANADACENSUS2006 SocialEnvironments The home environment plays a crucial role in well-being. Partners, community, and staff have said that there is less quality time for families and in many cases less family cohesiveness than there used to be. Support for families was considered very important. Several groups mentioned the importance of empowering parents through the development of positive parenting skills. There are a number of courses that have been offered over the years through Parent Child Coalitions and other groups. It was suggested that life skills such as parenting skills could be taught to students before leaving high school. First Nation partners mentioned the impact of residential schools, which was described as having contributed to a loss of parenting skills. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:53 One resource that staff and partners indicate is in short supply for residents of the Assiniboine Region is counselling for families and for couples. This was mentioned by staff from all of the community health programs. There are limited social work resources available through the regional health authority, and these resources are currently focused on positive parenting support, attachment, and family counselling through the Families First program. Other agencies exist to support children and families, but there is limited access to free counselling services for couples. Staff indicated that funded family/couple counselling would be beneficial for their clients. Health care workers have asked about supports available to military families living in Assiniboine communities. There is a significant military base in Shilo, just outside Brandon, and many military families live in surrounding communities within the Assiniboine region. Over the past few years, troops from Shilo have been deployed to Afghanistan. Returning home to Canada can be a difficult transition after deployment. Counselling and support services are available at the Shilo Military Family Resource Centre for individuals, couples, and families. Referrals to other local agencies and services are also available. Members of the military and their families who live in communities outside the Base may access services through their local health unit. As with many other residents of the region, there may be concerns related to confidentiality when members of the military or their families seek support services. Similarly, there may be reluctance to seek help for career-related reasons. Some families are fortunate to have supportive neighbours who help them through difficult times. PersonalHealthPracticesandCopingSkills There is a strong influence on health from the social environments we live and work in. These environments can support healthy choices or draw people towards less healthy decisions. There is evidence that negative environments and experiences can create changes in our bodies that increase the risk of illness. Health care providers and partners discussed the necessity for people to develop healthy coping skills. They also mentioned that it is important to deal with underlying causes of issues before looking to medication to fix them. Health behaviours among Assiniboine residents will be discussed in more detail in the following chapter. PG:54CHAPTER2:SOCIALANDECONOMICDETERMINANTSOFHEALTH ChapterHighlights Our high school completion rate, at 86%, is the best in the province. Low income rates in both individual and household are low compared to the provincial average. The rate of unemployment in the region is among the lowest in Manitoba. There has been an increase in the proportion of residents reporting speaking languages other than English and French in the home. Both culture and language have a strong influence on health and the ability to access health care. A growing immigrant population is likely to increase demands for primary care and access to interpretation. There is concern about child development and school readiness. Concerns have been expressed about access to safe, suitable housing and transportation. Generally, there are good social supports in our communities, but a lack of funded counselling for couples and families was identified as a need. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:55 Chapter3:LifestyleorBehaviouralRiskFactors There are a wide variety of ‘lifestyle’ or behavioural risk factors that influence the health of individuals and groups including, but not limited to, tobacco and alcohol use, diet and physical activity. Health promotion is the process of enabling individuals and communities to increase control over and improve their health by addressing (along with the social and economic determinants of health) these factors. Numerous health promotion activities occur throughout the Assiniboine Region annually. In recent years, nutrition, tobacco reduction, and physical activity along with the Chronic Disease Prevention Initiative have been priorities in the Region. During discussions with community, staff, and partners, personal responsibility for health was mentioned often. It was felt that the health care system was an important resource for health, but many people mentioned the importance of recognizing that we all have a part to play in maintaining our own health. The value of positive role models and leading by example was mentioned as well. Community, staff, and partners spoke about the resources required for healthy living. Often making the healthy choice can be expensive. Those we consulted felt it would be ideal if we could make healthy choices more affordable. BodyMassIndex The body mass index (BMI), index, is a statistical measurement which compares a person's weight and height. Though it does not actually measure the percentage of body fat, it is a useful tool to estimate a healthy body weight based on how tall a person is. Due to its ease of measurement and calculation, it is the most widely used diagnostic tool to identify weight problem within a population. The percentage of residents aged 18+ that are either overweight or obese according to this scale are detailed in Figure 3.1. According to the Canadian Community Health Survey, 61% of the region’s residents aged 18+ are estimated to be overweight with 25% classified as obese. Thirty-nine percent (39%) are considered either to be of normal weight or underweight. A district level analysis of BMI shows a significantly higher rate in the North 1 district of the region. It should be noted that the data does not include residents from First Nation reserves and is based on self-reported weight and height. Community members, partners and staff were concerned with rising rates of obesity, particularly among children and youth. PG:56CHAPTER3:LIFESTYLEORBEHAVIOURALRISKFACTORS Figure 3.1 Body Mass Index (BMI) Aged 18+ (Overweight and Obese – Age and Sex AdjustedCCHS20012005) OVERWEIGHT OBESE 38% SouthEastman 21% 34% Central 26% Assiniboine 36% Brandon 36% 25% 21% 34% Winnipeg 18% Interlake 38% NorthEastman 38% Parkland 39% 27% 22% 24% 35% NorMan 28% 38% Burntwood 30% 35% RuralSouth 24% 38% Mid 25% 36% North 28% 35% Manitoba 0% 10% 21% 20% 30% 40% 50% 60% SOURCE:MCHPRHAINDICATORSATLAS2009 TheCanadianCommunityHealthSurvey(CCHS)isconductedbyStatisticsCanadato provideregularandtimelycross–sectionalestimatesofhealthdeterminants,health statusandhealthsystemutilizationfor136healthregionsinCanada.Thesurvey excludespopulationslivinginIndianReserves,onCanadianForcesBases,andinsome remoteareas,andthosenotlivinginhouseholds. 70% ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:57 According to the Canadian Community Health Survey, 23% of children in the region between the age of 12 and 19 are estimated to be either overweight or obese. This is higher than suggested by the Youth Health Survey which was conducted in the Assiniboine region in 2006/2007 that suggested 17% of males and 11% of females were either overweight or obese using the same BMI measurement tool. Both sets of results are self-reported which can often lead to overestimation of height and underestimation of weight. Being overweight during childhood can lead to increased illness and risk of chronic diseases such as heart disease, cancer, and type 2 diabetes. Overweight and obese youth are often stigmatized by peers and adults. These youth may experience psychological stress, have a poor body image, as well as poor self-esteem. Figure3.2BodyMassIndex(BMI)Aged1219(OverweightandObese–SexAdjusted CCHS20012005) 22% SouthEastman 21% Central 23% Assiniboine 28% Brandon 23% Winnipeg 29% Interlake 24% NorthEastman 26% Parkland 31% NorMan 35% Burntwood 22% RuralSouth 23% Mid 33% North 25% Manitoba 0% 5% 10% 15% 20% 25% 30% 35% 40% SOURCE:MCHPCHILDHEALTHATLAS2008 TheYouthHealthSurveywasconductedwithGrade6toGrade12studentsinschools withintheAssiniboineRegionalHealthAuthorityfromDecember2006through March2007.Thesurveyaddressed,primarily,riskfactorsinchronicdiseasesuchas physicalactivity,healthyeating,andtobacco,alcohol,anddruguse. PG:58CHAPTER3:LIFESTYLEORBEHAVIOURALRISKFACTORS HealthyEating Healthy eating is an important part of a healthy lifestyle. Community dietitians work as part of the Health Promotion Team to partner with communities, schools, daycares, recreation facilities, and other groups within Assiniboine Regional Health Authority. The Health Promotion Team advocates healthy eating for good health and to prevent chronic disease through a variety of programs and activities. Some activities the community dietitians are involved in are presentations in schools and community, cooking classes, healthy food in recreation facilities, grocery store tours, food security, weight loss classes, and Nutrition Month. “Move to Healthy Choices” is a partnership project the community dietitians participated in developing that addresses healthy food in recreation facilities. This project recently won the 2010 President’s Award for Outstanding Achievement from the Recreation Connections Manitoba Board of Directors. Community members discussed that it can be expensive to purchase healthy foods in rural Manitoba, particularly in the winter. According to the Health Promotion Team, the price of vegetables increased 20% in the previous year. The importance of healthy eating was mentioned by many groups involved in the CHA process. It was recognized by youth and adults that healthy eating is essential in childhood and adolescence. School partners identified that there could be improvements in the foods some students bring to school. It was also mentioned that families may have less time for food preparation for a variety of reasons. A few high school students expressed an interest in having more healthy foods offered in schools, sporting events, and fairs, as well as reducing the availability of fast food. Seniors may experience challenges in maintaining a healthy diet. A number of communities in the Assiniboine region offer Meals on Wheels and congregate meal programs. These are considered important supports in our communities. The Meals on Wheels programs tend to rely on volunteers to deliver meals, which can pose challenges in providing regular service. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:59 FruitandVegetableConsumption Health Canada’s Guide to Healthy Eating recommends that we eat between 6 and 10 servings of fruit and vegetables per day depending on age and gender. The following results from the Canadian Community Health Survey suggests that 35% of residents aged 12 and over consume at least 5 servings a day which is slightly, but not significantly, higher than the provincial average at 33%. Figure3.3DailyFruitandVegetableConsumptionAges12+(AgeandSexAdjusted CCHS20012004)5orMoreServingsperDay SouthEastman 27% 32% Central 35% Assiniboine Brandon 32% 34% Winnipeg Interlake 32% 38% NorthEastman 30% Parkland NorMan 36% 33% Burntwood RuralSouth 32% 33% Mid North 34% Manitoba 33% 0% 5% 10% 15% 20% 25% 30% 35% 40% SOURCE:MCHPRHAINDICATORSATLAS2009 For children between the ages of 12 and 19, the recommended daily intake of fruit and vegetables is between 6 and 8, again depending on age and gender. For this age group the percentage of residents who have 5 or more servings per day is estimated at 39% by the Canadian Community Health Survey. This is not confirmed by the Assiniboine Youth Health Survey which suggests a much lower value of only 11% in both males and females. 45% PG:60CHAPTER3:LIFESTYLEORBEHAVIOURALRISKFACTORS Figure3.4DailyFruitandVegetableConsumptionAges1219(SexAdjustedCCHS 20012004)5orMoreServingsperDay 25% SouthEastman 31% Central 39% Assiniboine 31% Brandon 32% Winnipeg 31% Interlake 33% NorthEastman 39% Parkland 31% NorMan 24% Burntwood 31% RuralSouth 33% Mid 26% North 32% Manitoba 0% 5% 10% 15% 20% 25% 30% 35% 40% SOURCE:MCHPCHILDHEALTHATLAS2008 FoodSecurity Food security, a recognized determinant of health, is a growing concern in communities. Many communities in the Assiniboine region have established food banks in order to provide individuals and families access to food in times of need. Community members report increasing use of food banks in the past few years. The Health Promotion Team including community nutritionists offer: food skills workshops such as healthy baking and cooking classes, and nutrition education through presentations and workshops to schools and various community groups. The community nutritionists have done presentations about alternative food delivery systems such as the “good food box”. They also promote self-provisioning activities such as home gardening and community gardens. The community nutritionists have knowledge of the emergency food programs that are available for clients such as food 45% ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:61 banks or food cupboards. They also promote and support school based feeding programs such as the fruit and vegetable program at Waywayseecappo First Nation school. The Manitoba Prenatal Benefit is a monthly cheque during pregnancy which is available to income-eligible women to help with eating well. Pregnant women who live in Manitoba and have a net family income of less than $32,000 are eligible for prenatal benefits starting in the second trimester of pregnancy. Benefits end in the month the baby is due. In the recent Adult Health Survey conducted in 14 communities across the Assiniboine Region, 11% of people said that in the past year they worried sometimes or often that there would not be enough to eat because of lack of money. There were differences among communities, ranging from 3% in one community up to 23% in another community. There were a significantly higher proportion of females (13%) than males (8%) who worried about having enough money for food. In the same survey, 5% of people said that in the past year they sometimes or often did not have enough food to eat because of a lack of money. Again, there were differences among communities, with the range from 1% in one community to 20% of people from another community. In this same community, 24% of women reported not having enough to eat because of lack of money. Lack of money can impact the quality of food eaten. In the Adult Health Survey, 14% of people said they sometimes or often did not eat the quality of food they wanted to eat because of lack of money. PhysicalActivity Appropriate levels of physical activity have been demonstrated to promote normal growth and bone development, foster psychological well being, self-esteem, and social development, to help maintain a healthy body weight, and to reduce the risk of several chronic diseases including diabetes, high blood pressure, heart disease, and cancer. According to the Canadian Community Health Survey, 41% of the region’s residents aged 15-75 were classified as being active, considerably higher than the Manitoba average of just 29%. PG:62CHAPTER3:LIFESTYLEORBEHAVIOURALRISKFACTORS Figure3.5TotalPhysicalActivityLevelsAge1575(Work,LeisureandTravel)(Ageand SexAdjustedCCHS20012005) ACTIVE MODERATE INACTIVE SouthEastman Central 41% Assiniboine 30% 29% Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood 37% RuralSouth 30% 33% Mid North 29% Manitoba 0% 10% 34% 20% 30% 40% 37% 50% 60% 70% 80% 90% 100% SOURCE:MCHPRHAINDICATORSATLAS2009 In children between the ages of 12 and 19, the levels of activity are similar with 25% being classified as inactive, compared to a Manitoba average of 32%. Males are considerably more likely to be considered active than females. These results are confirmed by the Youth Health Survey which found that 46% of female students and 58% of male students participate in the recommended amount of physical activity daily according to the Public Health Agency of Canada’s Physical Activity Guide. School partners mentioned that while some students are extremely busy with extracurricular activities, including sports, others seem to do very little physical activity. This is reflected in delayed acquisition of gross motor skills. Community partners involved in recreation discussed the inability of many kids to master the basic techniques in some recreational activities (e.g. skiing) due to lack of strength and underdeveloped gross motor skills. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:63 The importance of getting children active early was discussed as a way to help them develop the habit of physical activity that will carry forward into their adult years. It was suggested that families may have less time for physical activity if parents are working or for other reasons. Figure3.6PhysicalActivityLevelsAge1219(SexAdjustedCCHS20012005) ACTIVE MODERATELYACTIVE INACTIVE SouthEastman Central 50% Assiniboine 25% 25% Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood RuralSouth 45% 23% 32% 44% 24% 32% Mid North Manitoba 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% SOURCE:MCHPCHILDHEALTHATLAS2008 Affordability of recreational activities and sports was mentioned often. The cost of fees, equipment, and travel can be a barrier for some families to participate in these activities. There are programs such as KidSport that provide some financial assistance, but it can be difficult for families to ask for this type of help. Community members, including youth, indicated that in some areas there are limited facilities available for recreation. In a telephone survey of a random sample of Assiniboine residents, 13% said that they do not have access to places for physical activity in their communities (Assiniboine Regional Health Authority, 2009). There is interest in additional recreation opportunities across the region, and the Chronic Disease Prevention Initiative has helped to facilitate these opportunities in some of our communities. Through the community engagement process, it was suggested that communities might partner with schools to make the gym available after school hours to PG:64CHAPTER3:LIFESTYLEORBEHAVIOURALRISKFACTORS allow for more physical activity opportunities. This does happen in many communities, but may depend on school division policies. Walking is considered an easy, affordable form of physical activity. For some residents, safety when walking can be a concern. Icy streets in the winter and worries about personal safety when walking after dark were mentioned as possible barriers to physical activity. When asked if they felt safe walking after dark, the majority (91%) of people said in the Adult Health Survey that they did. Males were more likely to report that they felt safe than females. To support physical activity efforts in the ARHA, the Health Promotion Team has partnered in the past with the Manitoba Fitness Council and offered Active Living Facilitator Training which allows trained leaders to promote Physical activity at the local level. A new resource called the Activity Breaks Resource for Schools was recently developed by a University of Manitoba kinesiology student who completed her practicum placement with the ARHA. This resource is full of simple ideas allowing interested schools to find fun ways to build physical activity into the lives of children so that they may reach or exceed the recommendations for active time as per the Canadian Physical Activity Guide for Children and Youth. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:65 Smoking The short and long-term health consequences associated with smoking are well known. Twenty-two percent (22%) of all deaths in Canada are attributed to smoking. Smoking causes 4 times as many deaths as car accidents, suicide, homicide, and AIDS combined. Half of all long-term smokers will die or be disabled by a smoking-related illness. The percentage of current smokers in the region is the lowest in the province according to the Canadian Community Health Survey at just 19.2%. Figure3.7SmokingRatesAge12+(AgeandSexAdjustedCCHS20012005) CURRENTSMOKER FORMERSMOKER NONSMOKER SouthEastman Central 19% Assiniboine 39% 42% Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood 21% RuralSouth 40% 39% Mid North 23% Manitoba 0% 10% 39% 20% 30% 40% 38% 50% 60% 70% 80% 90% 100% SOURCE:MCHPRHAINDICATORSATLAS2009 In children aged between 12 and 19, the number of current smokers in the region is also low, but the difference is less significant with 87% having smoked less than 100 cigarettes in their lifetime, compared to the provincial average of 85%. The chart shows the percentage of 12-19 year olds who have smoked less than 100 cigarettes in their lifetime. It should be noted that residents of First Nation reserves are not included in this data. PG:66CHAPTER3:LIFESTYLEORBEHAVIOURALRISKFACTORS Figure3.8AdolescentSmokingRatesAge1219(Smokedlessthan100cigarettesin theirlifetime)(SexAdjustedCCHS20012005) SMOKEDLESSTHAN100CIGARETTES SouthEastman Central 87% Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood 86% RuralSouth Mid North 85% Manitoba 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% SOURCE:MCHPCHILDHEALTHATLAS2008 Because 85% of current smokers start smoking by the age of 19, adolescence is a crucial time in the prevention of smoking. The average age for smoking initiation in the region is 14, comparable with that of Manitoba as a whole. There are no significant differences in smoking rates or initiation dependent on gender or area-level income. An alternative source of data, The Canadian Tobacco Use Monitoring Survey indicates that 20% of youth aged 15 to 19 in Manitoba and 19% of youth aged 15 to 19 in Canada were current smokers in 2005. Data from The Assiniboine Regional Health Authority Youth Health Survey gives a higher youth smoking rate for the region of 22% for grades 9 to 12. The Health Promotion Team is a partner in a number of initiatives that are designed to prevent and reduce tobacco use. This year, for National Non-smoking Week (NNSW), the team coordinated a regional activity which identified staff who had quit smoking. Through this awareness and recognition campaign, 21 employees sent in a submission. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:67 Lungs are for Life (LAFL) is a program that focuses on smoking prevention for Grades 4 to 6 students. ARHA Health Promotion Coordinators are trained to deliver this one-time program that offers hands-on learning for students. The Health Promotion Team has also coordinated training for Junior and High school students, who then deliver the program to the younger grades. ExposuretoSecondHandSmoke Exposure to second–hand smoke can have deleterious effects on health, and children are particularly vulnerable to the negative effects of this exposure. Childhood second–hand smoke exposure has been linked to sudden infant death syndrome, respiratory illnesses including asthma, and middle ear disease. Information on exposure to second-hand smoke is taken from the Canadian Community Health Survey where respondents are asked about regular exposure to smoke in the home including household members and regular visitors, ‘does anyone smoke inside your home every day, or almost every day?’ Figure3.9SecondHandSmokeExposureAge12+(AgeandSexAdjustedCCHS2001 2005) SouthEastman Central 16% Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood 15% RuralSouth Mid North 17% Manitoba 0% 5% 10% 15% 20% 25% 30% 35% 40% SOURCE:MCHPRHAINDICATORSATLAS2009 PG:68CHAPTER3:LIFESTYLEORBEHAVIOURALRISKFACTORS The rate of second-hand smoke exposure in the region is 16%, very similar to the Manitoba average. This is much higher amongst youth with 26% of 12-19 year olds in the region being exposed to second-hand smoke in the home on a regular basis. This is slightly lower than the Manitoba average of almost 27%. In this age group, arealevel income has a significant effect with those in lower income areas being more likely to be exposed to second hand smoke in the home than those in higher income areas. The Assiniboine Youth Health Survey questioned school children about their attitude to smoke-free places. In the schools within the Assiniboine Regional Health Authority, 87% of the students surveyed responded ‘probably yes’ or ‘definitely yes’ to the question, “Do you think all public places (e.g. malls, arcades, restaurants, etc.) should be smoke free?” Sharing this information with the students and getting kids involved in advocating for smoke-free public places may reduce the likelihood that they will start to smoke and may help them to feel that it is okay to speak out in favor of non-smoking. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:69 AlcoholUse Alcohol abuse is associated with motor vehicle and aquatic injuries and deaths, vandalism, alcohol poisoning, and violence. Harmful use patterns started young and carried into adulthood exacerbate these problems, and chronic alcohol abuse may lead to a number of acute and chronic disease conditions. Self-reported heavy drinking (residents who reported having drank more than five drinks on at least one occasion in the last 12 months) for the region is relatively high at 42% compared to a Manitoba average of 38% and a Rural South average of just 34%. Figure3.10SelfReportedHeavyDrinkingAge12+(AgeandSexAdjustedCCHS2001 2005) SouthEastman Central 42% Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood 34% RuralSouth Mid North 38% Manitoba 0% 10% 20% 30% 40% 50% 60% SOURCE:MCHPRHAINDICATORSATLAS2009 Adolescent alcohol consumption tends to be discussed more in terms of social effects as excessive consumption is linked to vandalism, violence, traffic offences, and school absenteeism. Also of concern is the increased risk of unprotected intercourse and potential pregnancy associated with teen alcohol consumption which together would carry risks of fetal alcohol spectrum disorders if the alcohol consumption continued and the pregnancy was carried to term. The Canadian Community Health Survey reports on those younger adolescents between the ages of 12 and 15 who did not drink and those between the ages of 16-19 who did drink in the last twelve months. PG:70CHAPTER3:LIFESTYLEORBEHAVIOURALRISKFACTORS The percentage of adolescents aged 12 to 15 who did not consume alcohol in the last twelve months is particularly low for the region at 64% compared to the provincial average of 76%. This trend seems to follow into older adolescents with 84% of teenagers aged 16 to 19 consuming alcohol compared to only 78% in Manitoba as a whole. Figure3.11YoungerAdolescentsAged1215WhoDidNotConsumeAlcohol(Sex AdjustedCCHS20012005) SouthEastman Central 64% Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood 76% RuralSouth Mid North 76% Manitoba 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% SOURCE:MCHPCHILDHEALTHATLAS2008 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:71 Figure3.12OlderAdolescentsAged1619WhoDidConsumeAlcohol(SexAdjusted CCHS20012005) SouthEastman Central 81% Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood 77% RuralSouth Mid North 78% Manitoba 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% SOURCE:MCHPCHILDHEALTHATLAS2008 The frequency of drinking amongst this age group is also of some concern with only 19% who did not drink compared to 52% who reported drinking less than once a week and 29% who consumed alcohol at least once a week. In comparison, the Manitoba rates are 22% non-drinkers, 55% less than once a week, and 23% at least once a week. This relatively high prevalence of alcohol use in the region seems to be supported by information gathered during the Assiniboine Youth Health Survey, where 80% of grade 12 students reported consuming alcohol in the last 30 days. Twenty-seven percent (27%) of these indicated that they had 5 or more drinks of alcohol within a couple hours on at least occasion in the past 30 days. When consulted, youth indicated that alcohol and drugs are among the most important issues facing young people today. Health care providers who work with youth say that it would be valuable to have healthy lifestyle programs to increase self-esteem and resilience to minimize high risk behaviour among youth. Youth have said they would like more education about drugs and alcohol. Partners from organizations that work with addictions feel that social programs which provide alternatives to drugs and alcohol would be beneficial. Cultural norms related to PG:72CHAPTER3:LIFESTYLEORBEHAVIOURALRISKFACTORS drinking were discussed. It was mentioned that drinking to intoxication is a common and sometimes expected practice in some groups. The suggestion was made that it would be more effective to “teach people how to drink before they develop problems rather than trying to fix a social problem with an individual remedy.” Partners in addiction services discussed the need for detox facilities and the limitations of using rural hospitals for this purpose. While the hospital staff try their best to accommodate these clients, they are “not always able to meet the needs of the individual who is struggling with alcohol and drug issues.” Rural hospitals generally do not require people to complete a course of treatment against their will and clients with addiction issues may be readmitted several times in a short period of time as a result of the choices they make. Staff mentioned the importance of having AFM residential beds for clients with addictions. As with other services, confidentiality can be a concern when seeking help for addictions. It is important to foster good communication among agencies who provide services to people with addictions in order to facilitate consistent treatment plans for their clients. IllegalDrugUse As part of the Assiniboine Youth Health Survey, school age children were asked about their illicit drug use. Ten percent (10%) of students in the schools indicated that they had used illegal drugs such as marijuana, cocaine, heroin, methamphetamines, ecstasy, steroid pills/shots, or sniffed glue in the past 30 days. When this is broken down by grades 9 to 12, we find that 7% of grade 9 students used illegal drugs in the past 30 days, but this increases to 21% by grade 12. With more disposable income, it may be getting easier for students to obtain drugs in our communities. While drugs were available in many communities in the past, there are some different drugs available now, such as crystal meth. Partners have said that drugs may be more readily available than in the past. RiskFactorSurveillance The Assiniboine region has been involved in assessing the population’s risks for chronic disease through two initiatives in recent years. In 2007, all school divisions in the region were invited to participate in a Youth Health Survey, based upon a school survey developed by the Interlake Regional Health Authority. In the participating schools, 80% of students from Grades 6 to 12 took part in the survey. In the survey, students were asked about their risk factors for chronic disease such as; healthy eating, physical activity, tobacco, alcohol and substance use, personal wellbeing, and school connectedness. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:73 Each participating school received a report that included results for their students. Each division had a summary and there is a copy of the regional Youth Health Survey available on the Assiniboine Regional Health Authority website at: http://www.assiniboine-rha.ca/index.php/services/view?id=22. Some schools and CDPI groups have used the results from the Youth Health Survey when doing school planning and developing health promotion activities that address the risk factors identified in the reports. In 2008/09 the Assiniboine region received a grant from the Public Health Agency of Canada to conduct an Adult Health Survey. This was a telephone survey of a random sample of people from a number of CDPI communities and several communities that did not have CDPI projects. The results from this survey may be helpful for CDPI committees and other communities to identify initiatives that may benefit the health of residents. SelfRatedHealth As part of the Canadian Community Health Survey, participants are asked “In general, would you say your health is: excellent, very good, good, fair, or poor and given the clarification, “By health we mean not only the absence of disease or injury but also physical, mental, and social wellbeing” The self-rated health of the region’s residents is amongst the best in the province with only 9.4% rating it as ‘fair or poor’ (the lowest of any region), significantly below the provincial value of 11.6%. While 18.9% rated their health as ‘excellent’, 43.9% rated it as very good and 27.7% rated it as ‘good’. Table 3.1 SelfRated Health Aged 12+ RHA and District (Age and Sex Adjusted CCHS 20012005) Excellent VeryGood Good Fair/Poor East2 21.7% 45.3% 23.3% 9.7% West1 21.2% 41.1% 27.0% 10.8% North1 13.2% 41.3% 34.2% 11.3% West2 16.7% 48.1% 26.7% 8.6% East1 19.3% 45.5% 27.5% 7.8% North2 18.3% 38.8% 32.4% 10.5% Assiniboine 18.9% 43.9% 27.7% 9.4% Manitoba 21.9% 38.8% 27.7% 11.6% SOURCE:MCHPRHAINDICATORSATLAS2009 At a district level there appears to be a generally slightly lower perception of health status in the north of the region in districts North 1 and North 2. PG:74CHAPTER3:LIFESTYLEORBEHAVIOURALRISKFACTORS Figure3.13SelfRatedHealthAged12+(AgeandSexAdjustedCCHS20012005) EXCELLENT VERYGOOD GOOD FAIR/POOR SouthEastman Central Assiniboine 19% 44% 28% 9% Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood RuralSouth 21% 40% 22% 39% 28% 11% Mid North Manitoba 0% 10% 20% 30% 40% 28% 50% 60% 70% 12% 80% 90% 100% SOURCE:MCHPRHAINDICATORSATLAS2009 FunctionalPhysicalHealth The physical functioning scale is a measure derived from the SF-36 questionnaire, addressing basic physical functioning on a scale of 0-100 (0 meaning unable to bathe or dress or walk one block; 100 meaning capable of vigorous activity). 56.8% of residents received a perfect score compared to 55.6% in Manitoba as a whole. The remainder having less than perfect physical functioning. There was no great disparity shown on a district level, however less than 50% of residents in the East 2 district reported perfect physical functioning whilst the other districts were similar to the regional value. The SF36 (ShortForm 36) is a questionnaire utilised in the Canadian Community Health Survey designed to evaluate the health of an individual in eight distinct categories. Each category is given a score of 0100 with each question given equal weight. The categories are: vitality, physical functioning, bodily pain, general health perceptions, physical role functioning, emotional role functioning, social role functioning,andmentalhealth. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:75 ChronicDiseasePreventionInitiative(CDPI) CDPI is a collaborative initiative designed to prevent and manage chronic diseases such as diabetes, cancer, cardiovascular, kidney and respiratory disease, which are all major causes of illness, disability, and death in Manitoba. The CDPI initiative is jointly funded by Manitoba Health and the Public Health Agency of Canada and supported by the Assiniboine Regional Health Authority. The vision of CDPI is to improve the health of Manitobans through local partnership, citizen engagement, and community development. Regional health authorities and government provide training, funding, and support, but CDPI projects are community initiated, planned, and led. Participating communities design programs to address the risk factors that affect their community. This is done through initiatives which promote active living, encourage healthy eating, and support people to live smoke-free. Some of the local project ideas that communities are working on across the Assiniboine region include: Supporting healthy choices for youth e.g. hot meals or vegetable snacks at schools, or new ways to be active Promoting healthy eating at local events and in community cafeteria settings Finding ways to partner with other local groups to promote physical activity opportunities e.g. community walking challenges Improving access to fruit and vegetables through community gardens Linking different age groups together to learn new skills e.g. intergenerational dancing and cooking classes Creating environments to support active living e.g. walking trails and skating ovals Chronic disease prevention initiatives can be found in 10 communities across the Assiniboine RHA: Erickson, Hamiota, Killarney, Minnedosa, Neepawa, Rossburn, Shoal Lake, Treherne, Virden, and Waywayseecappo. Get Better Together! is a free six-week workshop for people with ongoing health conditions to take control of their health. It is a self-management program for anyone living with a chronic disease, ongoing health concern, or disability, from type 2 diabetes, heart disease, arthritis and chronic pain, to Parkinson’s, asthma, depression, and cancer. Get Better Together! consists of workshops delivered in a community setting. People with chronic conditions discuss solutions for frustration, fatigue, pain, and isolation, effective communication with health professionals and appropriate exercise and nutrition. Participants receive a copy of the book Living a Healthy Life with Chronic Conditions and they are welcome to bring a support person to the sessions. The workshops are led by trained volunteer peer leaders who are themselves coping with chronic conditions, which is one component that makes the program so successful. PG:76CHAPTER3:LIFESTYLEORBEHAVIOURALRISKFACTORS Get Better Together! has been offered in a number of communities in the Assiniboine region and is supported by the Assiniboine Regional Health Authority, the Wellness Institute at Seven Oaks General Hospital, and Manitoba Healthy. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:77 ChapterHighlights There appear to be high levels of alcohol use in adolescents and adults. The value of healthy lifestyles was recognized, with interest in improving choices in communities. Communities have embraced the Chronic Disease Prevention Initiative, developing innovative, community led activities to promote healthy living. There is concern about obesity, particularly among children. Food security is a growing concern in communities. PG:78CHAPTER3:LIFESTYLEORBEHAVIOURALRISKFACTORS ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:79 Chapter4:BurdenofIllness An important measure of the health of the population is the proportion of the population diagnosed with a medical condition. This can be estimated by counting visits to physicians and admissions to hospitals, although these statistics will not capture the number of people who have not yet been diagnosed with a condition or those who have not sought care for a condition for a long time. Community, partners, and staff discussed the tendency to treat some conditions with medication without looking to the root causes of the issue. In some situations, life circumstances can be a major contributing factor to health problems. Treating a problem without addressing the cause often leads to relapse. CardiovascularDisease Cardiovascular diseases are the group of conditions that affect the heart and/or blood vessels and include hypertension, heart attacks, strokes, and ischemic heart disease. According to the Heart and Stroke Foundation of Manitoba, cardiovascular disease (heart disease and stroke) is the leading cause of death in Manitoba, Canada, and the world. HypertensionTreatmentPrevalence Hypertension, or high blood pressure, amongst residents aged 19 and over in the region (and at a district level) is consistent with the Manitoba average and has increased steadily between 2000/01 and 2005/06 so that almost one in four residents have been diagnosed or is being treated for the condition. The MCHP Sex Differences report of 2005 showed a disproportionately low level of males (aged 25+) in the region diagnosed with hypertension which is consistent across the Rural South but not repeated in Manitoba as a whole. PG:80CHAPTER4:BURDENOFILLNESS Figure4.1HypertensionTreatmentPrevalence(Aged19+)2000/01and2005/06(Age andSexAdjusted) 2000/01 2005/06 MBAvg2000/01 MBAvg2005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0% 5% 10% 15% 20% 25% 30% 35% SOURCE:MCHPRHAINDICATORSATLAS2009 40% ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:81 HypertensionMortality The five-year mortality rate for male residents of the region suffering from hypertension is 1.34 times that of those not suffering and 1.26 times for females. These compare with Manitoba rates of 1.39 and 1.30 for males and females respectively. Rural South rates are higher at 1.50 times for males and 1.48 times for females. Table4.1FiveYearMortalityRateforthosewithandwithoutHypertension2001/02 2005/06(AgeAdjusted) Male Female WithHT WithoutHT WithHT WithoutHT Assiniboine 4.7% 3.5% 3.4% 2.7% RuralSouth 4.8% 3.2% 3.7% 2.5% Manitoba 5.0% 3.6% 3.8% 2.9% SOURCE:MCHPRHAINDICATORSATLAS2009 The ‘fiveyear mortality’ rate is a measure of the death rate by all causes of those residents(aged19+)withaspecificchronicdiseaseandthosewithout,withinafive year period. The values are ageadjusted to the Manitoba population to allow for meaningfulcomparisons. PG:82CHAPTER4:BURDENOFILLNESS IschemicHeartDisease(IHD)Prevalence Ischemic heart disease (IHD) is a disease characterized by reduced blood supply to the heart muscle, usually due to coronary artery disease (atherosclerosis of the coronary arteries). Its risk increases with age, smoking, high cholesterol levels, diabetes, and hypertension (high blood pressure). Depending on the symptoms and risk, treatment may be with medication, percutaneous coronary intervention (angioplasty), or coronary artery bypass surgery (CABG). Figure4.2IschemicHeartDisease(IHD)Prevalence(Aged19+)1996/972000/01and 2001/022005/06(AgeandSexAdjusted) 1996/972000/01 2001/022005/06 MBAvg1996/972000/01 MBAvg2001/022005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0% 2% 4% 6% 8% 10% 12% 14% SOURCE:MCHPRHAINDICATORSATLAS2009 The Assiniboine region has the lowest prevalence of ischemic heart disease in the province (7.2% 2001/02-2005/06), significantly below the Manitoba average (8.5% 2001/02-2005/06). The disease is more prevalent in males and amongst the elderly. Despite the low age and sex adjusted rates, because of the population demographics of the region, we have the second highest crude percentage of residents diagnosed with the ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:83 disease at 9.8% (5,149 residents) in 2001/02-2005/06 compared to a Manitoba average of only 8.8% in the same time frame. The disease is most prevalent in the West 2 district of the region. There is also a strong correlation with area level income in rural areas. The highest IHD prevalence is found in the lowest income areas. IschemicHeartDiseaseMortality The five-year mortality rate for residents with IHD is 1.4 times that of those without IHD for both males and females in the region. This compares favourably with both the Rural South and Manitoba as a whole where the rate is closer to 1.5 in the same time period. Table4.2FiveYearMortalityRateforthosewithandwithoutIschemicHeartDisease (IHD)2001/022005/06(AgeAdjusted) Male Female WithIHD WithoutIHD WithIHD WithoutIHD Assiniboine 6.5% 4.6% 6.2% 4.4% RuralSouth 6.7% 4.3% 6.7% 4.2% Manitoba 7.0% 4.7% 6.9% 4.6% SOURCE:MCHPRHAINDICATORSATLAS2009 AcuteMyocardialInfarction(HeartAttack)Rates Heart attack, or acute myocardial infarction (AMI), is one of the leading causes of death in Canada. Heart attacks can be life-threatening emergencies that happen when the coronary arteries (the blood vessels supplying blood to the heart muscle to keep it working) become blocked. Lack of blood damages the heart muscle, weakening its function, or stopping it altogether, which can be fatal. The predominant (mostly modifiable) risk factors for AMI are diabetes, smoking, hypercholesterolemia, high blood pressure, a family history of ischemic heart disease (IHD), obesity, high stress levels, and excessive alcohol use. Males are more at risk than females and men over the age of 45 and women over the age of 55 are also more at risk. The AMI rate for the region measures the number of hospitalizations or deaths due to AMI per one thousand residents aged 40 and over. The region’s rate is not significantly different from the Manitoba average and has decreased from 5.1/1,000 in the period 1996/97-2000/01 to 4.6/1,000 in the period 2001/02-2005/06. There were no significant district level variations in the region, however, there is a strong relationship between income levels in rural areas and AMI rates with AMIs being more prevalent in the lower income areas. There is also a significant gender variation with PG:84CHAPTER4:BURDENOFILLNESS males being more than twice as likely to suffer an AMI as females in all income areas. Crude rates of AMI (rates that are not age and sex-adjusted) are noticeably higher because of the population makeup of the region at 6.3/1,000 from 1996/97-2000/01 and 5.45/1,000 from 2001/02 to 2005/06. Figure4.3HeartAttack(AMI)Rates(Aged40+)per1,000residents1996/972000/01 and2001/022005/06(AgeandSexAdjusted) 1996/972000/01 2001/022005/06 MBAvg1996/972000/01 MBAvg2001/022005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0 1 2 3 4 5 6 7 8 SOURCE:MCHPRHAINDICATORSATLAS2009 AMIMortality AMI mortality is measured as the rate of all-cause in-hospital death occurring within 30 days of the first admission to a hospital with a diagnosis of heart attack. A patient’s risk of dying in the hospital after a heart attack depends on many factors. Some, such as age, cannot be modified, but treatments, particularly the timing of re-opening coronary arteries for blood flow (cardiac revascularization), are greatly increasing people’s chances of survival. Other care-related practices, such as adhering to expert guidelines and best practices, (see ACS Care Map later in this section) are also important to achieving better outcomes. Whilst not at the same rate, the in-hospital mortality rate for AMI has been declining in recent years along with Manitoba as a whole. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:85 Table4.3AMI30DayInHospitalMortality2003/042007/08(RiskAdjusted) 2003/04 2005/06 2004/05 2006/07 2005/06 2007/08 Assiniboine 9.8% 9.1% 9.2% Manitoba 9.6% 9.2% 8.6% SOURCE:CIHIHEALTHINDICATORS20072009 AMIReadmissionRates Unplanned readmissions following an AMI are indicative of the quality of care received during the initial stay and after discharge from the hospital. The risk of readmission following an AMI may be related to differences in adherence to clinical practice guidelines in hospital and after discharge, patient compliance with post-discharge therapy or the quality of follow-up care in the community. Other factors may include the availability of appropriate diagnostic or therapeutic technologies (angiograms or angioplasties) during the initial hospital stay as well as overall quality of care while in the hospital. Table4.4AMIHospitalReadmission2004/052007/08(RiskAdjusted) 2004/05 2006/07 2005/06 2007/08 Assiniboine 5.5% 5.3% Manitoba 5.8% 5.2% SOURCE:CIHIHEALTHINDICATORS20082009 PostAMIBetaBlockingPrescribing Beta blockers are drugs that are predominantly used for the management of cardiac arrhythmias, cardioprotection after myocardial infarction (heart attack), and hypertension. In the period from 2001/02-2005/06, 79% of Assiniboine residents who suffered an AMI filled a prescription for a beta blocker. This is a significant increase from just 64% in 1996/97-2000/01 and is comparable to the Manitoba average of 80%. The only district that did not see this increase was North 2 where a modest decrease was found. Whilst at the Manitoba level a higher proportion of males than females received a beta blocker prescription, this is not a pattern that is repeated in the Assiniboine region. PG:86CHAPTER4:BURDENOFILLNESS ACSCareMap In response to requests from hospital and EMS staff across the region for standardized guidelines for assessment and management of heart attacks, the Assiniboine region developed an Acute Coronary Syndrome (ACS) Care Map. The intent of the ACS Care Map was to provide staff with clear and consistent guidance on the management of people presenting in emergency rooms with chest pain or suspected heart attacks. Through this initiative, the literature was reviewed to identify current clinical practice guidelines. The ACS Care Map was developed and implemented by a team of staff in consultation with a nurse specializing in cardiac care from Brandon. This protocol was first pilot tested in Virden in 2007 and then progressively implemented in the other acute care hospitals. The ACS Care Map has been well received by nurses and physicians. CardiacCatheterization Cardiac catheterization is a procedure whereby a catheter is inserted into a chamber or vessel of the heart for either investigation and/or interventional purposes. It is used primarily to identify the extent and location of blockages in coronary arteries. The rate of cardiac catheterization in the region is the lowest in the province in both time periods at just 4.6/1,000 in 1998/99-2000/01 and 5.3/1,000 in 2003/04-2005/06 compared to Manitoba rates of 6.8/1,000 and 6.9/1,000 for the same time periods. The rates are particularly low in the North 1 and North 2 districts at just 4.6/1,000 and 4.8/1,000 respectively in 2003/04-2005/06. Catheterization rates are much higher for males than females, more than double in 2001/02-2003/04 but this is due to a higher rate of catheterization in the younger age groups (where males are much more likely to suffer an AMI than females) rather than any gender bias in treatment. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:87 Figure4.4CardiacCatheterizationRates(Aged40+)per1,000residents1998/99 2000/01and2003/042005/06(AgeandSexAdjusted) 1998/992000/01 2003/042005/06 MBAvg1998/992000/01 MBAvg2003/042005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood RuralSouth Mid North Manitoba 0 2 4 6 8 10 SOURCE:MCHPRHAINDICATORSATLAS2009 CardiacRevascularizationInterventions Cardiac revascularization procedures are used to restore or improve blood supply to the heart muscle, which reduces the symptoms of coronary heart disease, such as chest pain and weakness. Revascularization can improve the quality of patients’ lives and reduce mortality. There are two kinds of revascularization procedures: bypass surgery (CABG) and coronary angioplasty (PCI). PG:88CHAPTER4:BURDENOFILLNESS PercutaneousCoronaryInterventions(PCI)(Angioplasty) Percutaneous transluminal coronary angioplasty is a procedure that involves inserting a catheter into a coronary artery, then inflating a small balloon at the end of it to dilate the narrowed segment of the artery so that blood flows to the heart muscle. Coronary stents are often inserted at the same time to keep the artery open. As with cardiac catheterization the region has the lowest rates in the province at just 1.8/1,000 in 2001/02-2005/06 compared to a provincial average of 2.3/1,000. This represents a substantial increase over the earlier time frame where the rate was just 1.1/1,000 residents suggesting that the rate is getting closer to the provincial average. Again the difference is most notable in the North of the region with the lowest rates in the North 1 and North 2 districts. Figure4.5PercutaneousCoronaryInterventions(PCI)(Aged40+)per1,000residents 1996/972000/01and2001/022005/06(AgeandSexAdjusted) 1996/972000/01 2001/022005/06 MBAvg1996/972000/01 MBAvg2001/022005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood RuralSouth Mid North Manitoba 0.0 0.5 1.0 1.5 2.0 2.5 3.0 SOURCE:MCHPRHAINDICATORSATLAS2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:89 CoronaryArteryBypassSurgery(CABG) Bypass surgery, also known as coronary artery bypass graft, or CABG, is major surgery where a patient’s chest is opened. Blood vessels taken from other parts of the body are attached to a coronary artery to bypass blockages and restore blood flow to the heart muscle. It is a procedure more commonly used when there are multiple diseased vessels. Once again, the region shows the lowest rate for this intervention in the province at 1.2/1,000 in 2001/02-2005/06 compared to 1.5/1,000 in Manitoba as a whole. In contrast to PCIs and cardiac catheterizations however, the lowest rates are not present in the North but in the southeast corner of the region in district East 2. Figure4.6CoronaryArteryBypassSurgery(CABG)(Aged40+)per1,000residents 1996/972000/01and2001/022005/06(AgeandSexAdjusted) 1996/972000/01 2001/022005/06 MBAvg1996/972000/01 MBAvg2001/022005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood RuralSouth Mid North Manitoba 0.0 0.5 1.0 1.5 2.0 2.5 SOURCE:MCHPRHAINDICATORSATLAS2009 PG:90CHAPTER4:BURDENOFILLNESS The low rates of cardiac catheterization and cardiac revascularization interventions in the Assiniboine region are tempered somewhat by more recent data from the Canadian Institute for Health Information which suggests that the gap between the region’s rates for cardiac revascularization and Manitoba’s rates have narrowed dramatically in more recent years. Table4.5CardiacRevascularizationInterventionRates/100,00o(Age20+)(Age Standardized)2003/04and2007/08 20032004 20072008 Assiniboine Manitoba Assiniboine Manitoba CABG 84 103 75 85 PCI 69 127 141 131 Cardiacrevascularization 153 229 216 215 SOURCE:CIHIHEALTHINDICATORS2009 Whilst this only represents one year worth of data it is a continuation of a promising trend noticed in the earlier data from the Manitoba Centre for Health Policy. Stroke(CerebrovascularAccident)IncidenceRates A stroke or cerebrovascular accident (CVA) is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. As a result, the affected area of the brain is unable to function, possibly leading to inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or inability to see one side of the visual field. A stroke can cause permanent neurological damage, complications, and death. Risk factors for stroke include advanced age, hypertension, previous stroke or transient ischemic attack (TIA), diabetes, high cholesterol, and cigarette smoking. High blood pressure is the most important modifiable risk factor of stroke. The stroke incidence rate is the count of deaths or hospitalizations due to stroke in the population aged 40 and over. The age and sex adjusted rate for the region is almost identical to the Manitoba average and has dropped significantly between the two time periods. Stroke rates follow a very similar pattern to AMIs in that they are higher in low income rural areas and amongst men (although not to the same degree). There is no significant variation in rates at a district level in the region and crude rates are again significantly higher at 5.3/1,000 and 3.9/1,000 compared to the age and sex adjusted rates of 4.0/1,000 and 3.0/1,000 for the periods 1996/97-2000/01 and 2001/02-2004/05 respectively. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:91 Figure4.7StrokeIncidenceRates(Aged40+)per1,000residents1996/972000/01and 2001/022005/06(AgeandSexAdjusted) 1996/972000/01 2001/022005/06 MBAvg1996/972000/01 MBAvg2001/022005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0 2 4 6 8 10 SOURCE:MCHPRHAINDICATORSATLAS2009 StrokeMortality Stroke mortality is measured as the rate of all-cause in-hospital death occurring within 30 days of the first admission to a hospital with a diagnosis of stroke. Stroke is caused by either blocked blood flow to the brain (ischemic stroke) or rupture of blood vessels and bleeding into the brain (hemorrhagic stroke). Only about one in five strokes is caused by bleeding, but patients with hemorrhagic strokes have higher mortality rates. An important factor in stroke mortality is the quality of care provided, for example timely access to imaging technology such as computed tomography (CT) or magnetic resonance imaging (MRI) is essential in distinguishing the two types of strokes and deciding on appropriate treatment. MRI scan rates have increased dramatically in the region in recent years since the installation of an MRI scanner in Brandon Regional Health Centre in 2004 and are now PG:92CHAPTER4:BURDENOFILLNESS amongst the highest in the province (27.6/1,000 residents aged 20+ in 2004/05-2005/06 compared to a provincial rate of just 22.0/1,000 in the same time period). Early treatment with thrombolytics (clot busting medications) can benefit patients with ischemic strokes. Being cared for by a specialist or by a stroke team may also lead to better results. Mortality rates following stroke may reflect the severity of the stroke, the underlying effectiveness of treatment, and quality of care (see Stroke Strategy later in this section). Provincial stroke mortality has been steadily declining between 2003/04 and 2007/08. This pattern has not been repeated in the Assiniboine region where, despite fluctuations, the mortality rate has been consistently higher. The improvements in access to MRI scans since the installation of the MRI scanner in Brandon in 2004 has not led to any noticeable reduction in mortality. Table4.6Stroke30DayInHospitalMortality2003/042007/08(RiskAdjusted) 2003/04 2005/06 2004/05 2006/07 2005/06 2007/08 Assiniboine 25.3% 20.8% 22.1% Manitoba 19.0% 18.3% 18.2% SOURCE:CIHIHEALTHINDICATORS20072009 StrokeStrategy Stroke has been well established as a major cause of death and disability. In 2008 the Assiniboine Region established a Stroke Strategy planning task force in order to align stroke prevention and management with the current guidelines. The task force involves staff from disciplines across the region. To date, the Stroke Strategy has involved: Public awareness activities on stroke signs and symptoms, Staff awareness of stroke prevention clinics in Brandon, Staff awareness of education opportunities, Partnership with Brandon RHA to establish an EMS protocol to transport patients with certain symptoms directly to Brandon which will facilitate early access to scans that can guide treatment decisions, and A review of rehabilitation and community resources available to stroke patients. The task force would like to develop a Stroke Care Map for staff which would guide the assessment and treatment of people who may have had strokes. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:93 Diabetes Diabetes is a serious and highly prevalent chronic condition that currently affects over two million Canadians. In the Assiniboine region almost five thousand residents sought treatment for diabetes between 2003 and 2005. There are three main types of diabetes. Type 1 diabetes, usually diagnosed in children and adolescents, occurs when the pancreas is unable to produce insulin. Insulin is a hormone that ensures body energy needs are met. Approximately 10% of people with diabetes have type 1 diabetes. The remaining 90% have type 2 diabetes, which occurs when the pancreas does not produce enough insulin or when the body does not effectively use the insulin that is produced. Type 2 diabetes usually develops in adulthood, although increasing numbers of children in high-risk populations are being diagnosed. A third type of diabetes, gestational diabetes, is a temporary condition that occurs during pregnancy. It affects approximately 3.7% of all pregnancies in the non-Aboriginal population and 8 – 18% of all pregnancies in the Aboriginal population, and involves an increased risk of developing diabetes for both mother and child. If left untreated or improperly managed, diabetes can result in a variety of complications, including heart disease, kidney disease, eye disease, impotence, and nerve damage. The treatment prevalence of diabetes amongst adults in the region is increasing with time along with the rest of Manitoba; however the prevalence in the second time period 2003/04-2005/06 is significantly lower at 8.0% than the Manitoba average of 9.3%. This rate is still higher than the Rural South average of 7.6%. The only significant district level variation is in East 2 where there is significantly lower diabetes treatment prevalence. TreatmentPrevalenceisamethodofestimatingtheprevalenceofaconditionby countingthenumberofpeoplewhoseekorreceivetreatmentforthatcondition.It doesnotcountpeoplewiththeconditionwhoareundiagnosedorwhodonotseek treatment. PG:94CHAPTER4:BURDENOFILLNESS Figure4.8DiabetesTreatmentPrevalenceAged19+(AgeandSexAdjusted– 1998/992000/01and2003/042005/06) 1998/992000/01 2003/042005/06 MBAvg1998/992000/01 MBAvg2003/042005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0% 5% 10% 15% 20% 25% SOURCE:MCHPCHILDHEALTHATLAS2008 According to the Sex Differences report of 2005 from the Manitoba Centre for Health Policy, there is a significant gender difference in diabetes prevalence with males, particularly over the age of 45, being more likely to develop diabetes than females. Diabetes prevalence amongst children is significantly lower than that for adults and for the Assiniboine region does not appear to be increasing significantly with time. The region’s prevalence rate is almost identical to the Manitoba average of 0.41% of children aged 5-19. There is, however, a significant association between diabetes prevalence in children and area-level socioeconomic status in rural areas. The prevalence of diabetes was 53% higher in the lowest rural income areas compared to the highest rural income areas. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:95 DiabetesMortality The five-year mortality rate for people with diabetes is amongst the highest for any chronic disease. In the period 2001/02-2005/06, it was twice that of people without diabetes in the Assiniboine region and slightly higher for Manitoba as a whole at 2.2 times. The mortality rate is slightly higher amongst males than females for both Assiniboine and Manitoba as a whole. The pattern of diabetes mortality is repeated across all districts of the region other than East 1 where the rate is significantly lower amongst both males and females. Table4.7FiveYearMortalityRateforthosewithandwithoutDiabetes2001/02 2005/06(AgeAdjusted) Male Female With Diabetes Without Diabetes With Diabetes Without Diabetes Assiniboine 10.1% 5.0% 8.8% 5.0% RuralSouth 9.7% 4.9% 10.1% 4.8% Manitoba 11.7% 5.3% 10.5% 5.2% SOURCE:MCHPRHAINDICATORSATLAS2009 DiabetesCareEyeExams Diabetic retinopathy is damage to the retina caused by complications of diabetes, which can eventually lead to blindness. It affects up to 80% of all patients who have had diabetes for 10 years or more. Regular and vigilant treatment and monitoring of the eyes through annual eye exams has been shown to dramatically reduce the incidence of this condition. In 2005/06, 43% of residents with diabetes had an eye examination (the highest in the province) compared to 34% in Manitoba as a whole. This is a significant increase from the 2000/01 value of 38%. A higher proportion of females than males in the region had eye examinations, a pattern that is repeated in Manitoba as a whole. At a district level, only the North 1 and North 2 districts showed levels that were not significantly above the provincial average. PG:96CHAPTER4:BURDENOFILLNESS Figure4.9DiabetesCareEyeExaminationsAged19+2000/01and2005/06 2000/01 2005/06 MBAvg2000/01 MBAvg2005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0% 10% 20% 30% 40% 50% SOURCE:MCHPRHAINDICATORSATLAS2009 LowerLimbAmputations A variety of factors work in unison to cause foot problems in people with diabetes. These mainly involve poor circulation and nerve disease (neuropathy). Neuropathy affects the ability to feel pain or discomfort in the feet, making diabetics more susceptible to extensive injury-related damage. In addition, diabetes can impair the ability to heal by both damaging the immune system and decreasing blood flow in the legs. This can lead to bone and joint deformities. Diabetes can also affect the vision, making it more difficult to notice sores or injuries to the feet and an injury or infection may not be noticed until the condition is so serious that surgery is required, possibly resulting in amputation of the foot and even part of the leg. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:97 Risk factors for developing foot ulcers include; Age: Risk increases with age. Gender: Males are at higher risk. Race: Those of Aboriginal descent have a higher risk. Duration of diabetes: The longer one has diabetes, the greater the risk. Other complications from diabetes (small blood vessel disease or atherosclerosis of large blood vessels). Poor blood glucose control: Having blood sugar levels above a safe range over time speeds up the damage to blood vessels and nerves. Smoking, contributes to blood flow problems in the extremities. The rate of lower limb amputations amongst residents with diabetes is not significantly different from the Manitoba average at 1.21% of residents with diabetes (aged 19+) who had an amputation in the 5-year period 2001/02-2005/06. The Manitoba average for this same time period is 1.63%. The regional rate represents a decline from the 1998/992002/03 value of 1.38%. RegionalDiabetesProgram/RiskFactorComplicationAssessment The Assiniboine RHA’s Regional Diabetes program works in the areas of prevention, education, care, research, and support. The Regional Diabetes program staff consists of a coordinator, three community nutritionists/dietitians (registered dietitians), a registered nurse, a medical advisor, and educators with Prairie Health Matters (registered nurses and registered dietitians). Prairie Health Matters: Diabetes and Heart Health Education, a program based in Brandon RHA, provides education for diabetes and heart health in the Assiniboine RHA. Topics can include: healthy eating, label reading, use of sweeteners, medications, physical activity, blood sugar testing, etc. Education is offered to individuals and groups, and may be provided in person, or via Telehealth, with follow-up by telephone, email, or in person. Clients do not need to have a doctor’s referral to access this service. Prairie Health Matters also offers staff education opportunities, such as an annual Diabetes ABC workshop for staff of the Assiniboine and Brandon RHAs. The Regional Diabetes program offers diabetes-related workshops, in-services, presentations, and resources for people living with diabetes and for health care providers in the region. On an annual basis, the program partners with 5-7 of the First Nation communities, the Manitoba Métis Federation, the Brandon RHA, and the Canadian Diabetes Association to offer the Diabetes Gathering. This Gathering provides an opportunity for smaller First Nation communities such as Gambler First Nation (where the idea originated) to pool funds with other communities to develop a diabetes prevention workshop that has a great impact on all of the communities. The Diabetes Gathering is offered in a different community each year. At the time of writing, the committee was planning the 9th Annual Diabetes Gathering. PG:98CHAPTER4:BURDENOFILLNESS Another program of the Regional Diabetes program is the Wellness Screen. The Wellness Screen is a screening program for type 2 diabetes and some chronic diseases (such as heart disease). The goal of the program is to help people identify if they have diabetes are at risk for type 2 diabetes or complications from diabetes. This program was developed by Manitoba Health. It is also known as the Risk Factor and Complication Assessment. The Wellness Screen is offered in many communities throughout the ARHA in community settings and in workplaces and screened 134 residents in 2008/2009. Participants meet with a registered dietician and a registered nurse to have a confidential individual assessment. The dietician and nurse review with the client their: risk factors for developing type 2 diabetes, blood pressure, BMI (Body Mass Index), cholesterol and blood sugar level (if available), eating habits, and physical activity levels. The participants have the opportunity to ask questions and learn what they can do to stay healthy. They are encouraged to set a healthy living goal and may be referred to other resources for further education or care. There are a couple of communities in the Assiniboine region which host Diabetes Clinics. Each operates under a different model of assessment and care. A subcommittee of the Regional Diabetes program is currently working with these clinics in Hamiota and Rivers to implement promising practices in diabetes care that may lead to improved outcomes for clients. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:99 RespiratoryDiseases Respiratory disease is the term for diseases of the respiratory system. These include diseases of the lung, pleural cavity, bronchial tubes, trachea, and upper respiratory tract and of the nerves and muscles of breathing. Respiratory diseases range from mild and self-limiting such as the common cold, to life-threatening such as bacterial pneumonia or pulmonary embolism. They are a common and significant cause of illness and death in the region. TotalRespiratoryMorbidity(TRM)TreatmentPrevalence TRM treatment prevalence is a measure of the proportion of residents diagnosed (in at least one physician visit or hospitalization) with any of the following respiratory diseases: asthma, acute or chronic bronchitis, emphysema, or chronic airway obstruction. The region’s rate of respiratory morbidity is significantly lower than the provincial average in both time periods shown and has decreased between 2000/01 and 2005/06 in line with the rest of Manitoba. Table4.8TotalRespiratoryMorbidityTreatmentPrevalence2000/01and2005/06 (AgeandSexAdjusted) Assiniboine RuralSouth Manitoba 2000/01 11.1% 10.2% 12.4% 2005/06 9.8% 9.5% 11.6% SOURCE:MCHPRHAINDICATORSATLAS2009 PG:100CHAPTER4:BURDENOFILLNESS Figure4.10TotalRespiratoryMorbidityTreatmentPrevalence2000/01and2005/06 (AgeandSexAdjusted) 2000/01 2005/06 MBAvg2000/01 5% 10% MBAvg2005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0% 15% 20% SOURCE:MCHPRHAINDICATORSATLAS2009 TotalRespiratoryMorbidityMortality The five-year mortality rate for those residents with total respiratory morbidity was 1.41 times that for residents without TRM in the period 2001/02-2005/06. This is almost identical to the Manitoba average for the same time period of 1.44 times. The mortality rate for females with TRM in the region is considerably lower than both that for males in the region and for females in Manitoba as a whole. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:101 Table4.9FiveYearMortalityRateforthosewithandwithoutTotalRespiratory Morbidity(TRM)2001/022005/06(AgeAdjusted) Male Female WithTRM Without TRM WithTRM Without TRM Assiniboine 7.6% 5.2% 6.7% 5.2% RuralSouth 7.3% 5.0% 7.2% 5.1% Manitoba 7.7% 5.4% 7.9% 5.4% SOURCE:MCHPRHAINDICATORSATLAS2009 Asthma Asthma is a chronic lung disease caused by a complex interaction of environmental and genetic factors that are not fully understood. These factors can influence how severe a person’s asthma is and how well they respond to medication. Many environmental risk factors have been associated with asthma development and morbidity in children, particularly environmental tobacco smoke (especially maternal), poor air quality, and high ozone levels. Caesarean sections, psychological stress, and antibiotic use in early life have also been linked to the development of asthma. Table4.10AsthmaPrevalence–AgeStandardizedCasesper1,000Residents2002 2007 MALE 2002/ 2003 2003/ 2004 Assiniboine 44 Brandon 60 Burntwood FEMALE 2004/ 2005 2005/ 2006 2006/ 2007 2002/ 2003 2003/ 2004 2004/ 2005 45 46 62 60 46 47 46 44 44 46 47 59 59 64 65 62 64 67 33 32 30 32 32 44 43 43 44 46 Central 49 49 46 47 46 51 51 49 51 50 Interlake 57 58 59 58 60 61 63 62 63 62 NorthEastman 58 58 57 59 61 66 66 66 70 71 Norman 36 36 36 42 45 40 40 38 43 46 Parkland 49 49 49 49 47 59 54 55 58 57 SouthEastman 60 60 60 62 58 59 58 56 60 59 Winnipeg 72 72 73 75 75 78 77 78 81 81 Manitoba 62 62 62 64 64 68 67 67 69 69 2005/ 2006/ 2006 2007 SOURCE:MANITOBAHEALTHINFORMATIONMANAGEMENT2008 PG:102CHAPTER4:BURDENOFILLNESS The prevalence of asthma is the region is amongst the lowest in the province at 47 cases per 1,000 residents for both male and females. This is compared to a Manitoba average of 64/1,000 for males and 69/1,000 for females. These values however are highly influenced by the urban centers of Winnipeg and Brandon where the prevalence is much higher than in rural areas. A district level breakdown of rates shows a much higher prevalence (56/1,000 for males and 61/1,000 for females) in the West 1 district. This is significantly higher than the regional average. Chronic conditions are not common in childhood but asthma is the most frequent chronic condition in children. School partners felt that there are increases in the numbers of students attending school with asthma, but reports indicate that there has been only a small increase in the past few years. The Child Health Atlas report of 2008 gives the prevalence of asthma amongst children between the ages of 5 and 19 as 11.3% between 1999/2000-2000/2001 and 11.6% between 2004/05-2005/06 for the region. These compare with Manitoba averages of 13.7% and 13.9% for the same time periods. The Sex Differences report of 2005 reported on the proportion of asthmatics on appropriate long-term controller medications and found that residents of the ARHA are more likely to be on controller medications than residents of Manitoba as a whole. Fiftyeight percent (58%) of males and 57% of females were on controller medications compared to the Manitoba averages of 52% for males and 54% for females. RANARespiratoryClinics/HomeOxygen The RANA Respiratory Care Group delivers a community respiratory program in the region aimed at supporting individuals suffering from lung disease and those health care professionals involved in their care. The clinics offer education services and direct disease management including the development of a client specific action plan fundamental in dealing with the client’s respiratory illness. Respiratory Clinics are held across the region and in 2008/2009 there were 118 first-time visits and 239 follow-up visits made by the region’s residents. These numbers have remained relatively stable from the 2007/2008 values of 107 and 270 respectively. The majority of initial visits (84%) were as a result of referrals from physicians. Wait time for clinic visits has improved with the average waiting time for a clinic visit at 48 days in 2008/2009. This has dropped significantly from almost 60 days in 2007/2008. The two most common diagnoses for new referrals to the clinics in 2008/2009 were chronic obstructive pulmonary disease (COPD) (36%) and asthma (32%). ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:103 RANA delivers, in collaboration with the region’s Home Care program, a home oxygen service providing equipment and supplies to residents requiring oxygen in a home or PCH setting, as well as acting as a resource to home care case coordinators in assessing and assisting in the development of care plans for clients. In 2008/2009 there were 500 residents receiving these services compared to 598 in 2007/2008. RANA has also participated in a number of disease prevention and health promotion initiatives related to respiratory diseases including a children’s asthma educational program (The Roaring Adventures of Puff) and a partnership with the Assiniboine region to develop an educational program for chronic COPD patients. PG:104CHAPTER4:BURDENOFILLNESS OtherChronicConditions ArthritisPrevalence There are many different conditions that are considered to be types of arthritis. Arthritis causes joint and musculoskeletal pain, which is often the result of inflammation of the joint lining. Arthritis prevalence is a measure of the number of residents diagnosed and/or seeking treatment for the condition (rheumatoid or osteoarthritis). The region’s prevalence of 19.1% in 2004/05-2005/06 is comparable to 19.3% in the Rural South and slightly lower than the Manitoba average of just over 20%. The unadjusted value of 21.6% for 2004/052005/06 is higher than the Manitoba average, likely due to the disproportionate elderly population in the region more likely to suffer with the condition. Figure4.11ArthritisPrevalence(aged19+)1999/002000/01and2004/052005/06(Age andSexAdjusted) 1999/20002000/01 2004/052005/06 MBAvg1999/20002000/01 MBAvg2004/052005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood RuralSouth Mid North Manitoba 0% 5% 10% 15% 20% 25% SOURCE:MCHPRHAINDICATORSATLAS2009 30% ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:105 The MCHP Sex Differences report of 2005 found that, in common with Manitoba as a whole, the prevalence of arthritis amongst female residents is significantly higher than that amongst males (22.4% for females in the ARHA compared to 18.8% for males in 2003/04-2004/05) ArthritisMortality The five-year mortality rate for those residents with arthritis was 1.06 times that for residents without arthritis in the period 2001/02-2005/06. This is significantly lower than the Manitoba average for the same time period of 1.14 times. In contrast to males, the mortality rate for females with arthritis in the region is significantly different to those without. Table4.11FiveYearMortalityRateforthosewithandwithoutArthritis2001/02 2005/06(AgeAdjusted) Male Female With Arthritis Without Arthritis With Arthritis Without Arthritis Assiniboine 5.3% 5.2% 4.9% 4.3% RuralSouth 5.5% 4.9% 5.0% 4.3% Manitoba 5.9% 5.2% 5.3% 4.6% SOURCE:MCHPRHAINDICATORSATLAS2009 OsteoporosisTreatmentPrevalence Osteoporosis is a disease of the bone that leads to an increased risk of fracture due to a reduction in bone mineral density. It is most common in women after menopause (postmenopausal osteoporosis). The proportion of residents in the region aged 50 or older diagnosed with osteoporosis has increased significantly from 9.7% in 1998/992000/01 to 12.7% in 2003/04-2005/06. This is comparable to the Manitoba average but higher than the Rural South where rates are consistently lower than the Manitoba average. Osteoporosis is considerably more prevalent in women in the region, with 20.7% of females aged 50+ being diagnosed in the second period (2003/04-2005/06) compared to only 5.6% of men. This is not dissimilar to Manitoba as a whole. In contrast to most other chronic conditions, osteoporosis is not strongly related to health status or area level income. PG:106CHAPTER4:BURDENOFILLNESS Figure4.12OsteoporosisPrevalence(Aged50+)1998/992000/01and2003/04 2005/06(AgeandSexAdjusted) 1998/992000/01 2003/042005/06 MBAvg1998/992000/01 MBAvg2003/042005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% SOURCE:MCHPRHAINDICATORSATLAS2009 OsteoporosisMortality The five-year mortality rate for those residents with osteoporosis was 1.34 times that for residents without osteoporosis in the period 2001/02-2005/06. This is almost identical to the Manitoba average for the same time period of 1.35 times. Although the disease is considerably more prevalent in females, the mortality rate in the region (and Manitoba as a whole) is much higher in males at 1.45 times compared to 1.27 for females (1.50 and 1.20 for Manitoba). ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:107 Table4.12FiveYearMortalityRateforthosewithandwithoutOsteoporosis2001/02 2005/06(AgeAdjusted) Male Female With Without With Without Osteoporosis Osteoporosis Osteoporosis Osteoporosis Assiniboine 19.2% 13.2% 13.4% 10.5% RuralSouth 17.6% 12.8% 13.9% 10.5% Manitoba 20.5% 13.7% 13.8% 11.5% SOURCE:MCHPRHAINDICATORSATLAS2009 Cancer Cancer is a disease originating in body cells, which causes cells to form lumps or tumours. Early detection of tumours that are cancerous, or malignant, is an essential part of cancer care. Sometimes malignant cells will spread through the bloodstream or lymphatic system. There are many different types of cancer, which are named after the part of the body where they originated. CancerCare Manitoba (CCMB) is responsible for cancer prevention, detection, care, research, and education for the people of Manitoba. CCMB is dedicated to excellence in cancer care, to enhancing quality of life for those living with cancer and blood disorders, and to improving control of cancer for all Manitobans. The Community Cancer program (CCP) is a provincial program of CancerCare Manitoba, which enables patients to receive cancer care, treatment, and follow-up in or near their home communities. Collaboration between CancerCare Manitoba specialists and the staff of the CCP is supported through use of Telehealth, which offers opportunities for consultation and education via video and teleconferencing. Currently the Community Cancer program is available in Hamiota, Neepawa, Russell, and most recently Deloraine. These clinics, which have grown to play a role as cancer care centres of excellence at the local level, provide primarily chemotherapy treatments on a mostly outpatient basis as well as any supporting treatments, education, and counselling. The program benefits clients by reducing the need to travel for treatment. There are strong links to other regional programs, such as palliative care, volunteer programs, and external agencies like the Canadian Cancer Society. Community and staff mentioned that it can be difficult for clients with a cancer diagnosis and their families to navigate the health care system. It can be confusing for them when they are first entering the system, and they may not feel comfortable initially asking questions. Once clients are in the Community Cancer program, they are more comfortable discussing concerns with staff, who will then find the information they need. PG:108CHAPTER4:BURDENOFILLNESS There may be challenges navigating the system again at transition points, such as after clients leave the Community Cancer program upon completion of treatments or if they need to access palliative care services. Some groups who may experience challenges with meeting needs related to oncology services are children and young adults. First Nation residents may have difficulty obtaining transportation for treatment and follow-up. One area that staff working in oncology in the region would choose as a priority to improve is psychosocial support. The number of new referrals and treatments for the first nine months of 2009/2010 for each clinic are shown below. Table4.13ARHACommunityCancerProgramStatisticalSummary01/04/2009 31/12/2009 Russell Hamiota Neepawa Deloraine 31 13 25 13 OutpatientTreatments 229 94 278 65 InpatientTreatments 10 0 * 0 Newpatientreferrals *VALUESUPPRESSED SOURCE:CANCERCAREMANITOBA2010 The CCP staff indicate that there has been an increase in oncology activity in the last few years. They feel that there are higher numbers of clients with cancer of the lung and esophagus in the last year. The CCPs in the Assiniboine region are doing different types of treatments in order to reduce the demands on the Winnipeg treatment programs. Assiniboine CCP staff praise the support that CancerCare staff provide to them, as well as the education available. Community members believe that there has been an increase in the number of people diagnosed with cancer in recent years. Some wonder if there are areas of the region in which cancer is more prevalent because of the high number of people they know who have been diagnosed. CancerIncidence The incidence of cancer (new cases) amongst males in the region is very similar to the Manitoba average in both time periods at 557/100,000 in 2000-2002 and 505/100,000 in 2003-2005. This compares to the Manitoba rates of 559/100,000 and 527/100,000 for the same time periods. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:109 Figure4.13MaleCancerIncidenceper100,00020002002and20032005(Age Adjusted) MaleCI20002002 MaleCI20032005 MBAvg20002002 MBAvg20032005 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood Manitoba 0 100 200 300 400 500 600 700 800 SOURCE:CANCERCAREMANITOBA2009 By far the highest incidence of cancer amongst males is prostate cancer which accounted for 26% of all new cancer cases in 2003-2005. This is slightly higher than the Manitoba average for this cancer at 24% Table4.14MaleCancerIncidence/100,00020002002and20032005bySite(Age Adjusted) Assiniboine Manitoba 20002002 20032005 20002002 20032005 Colorectal 89.0 86.0 82.0 78.0 Lung 70.0 66.0 87.0 85.0 Prostate 169.0 133.0 148.0 127.0 Melanoma 14.0 16.0 13.0 12.0 ALL 556.5 504.3 558.6 527.4 SOURCE:CANCERCAREMB2009 PG:110CHAPTER4:BURDENOFILLNESS The incidence of cancer (new cases) amongst females in the region is noticeably lower than that for males but again is also very similar to the Manitoba average in both time periods at 437/100,000 in 2000-2002 and 423/100,000 in 2003-2005. This compares to the Manitoba rates of 434/100,000 and 427/100,000 for the same time periods. Figure4.14FemaleCancerIncidenceper100,00020002002and20032005(Age Adjusted) FemaleCI20002002 FemaleCI20032005 MBAvg20002002 MBAvg20032005 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood Manitoba 0 100 200 300 400 500 600 SOURCE:CANCERCAREMANITOBA2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:111 The highest incidence of cancer amongst females is breast cancer which accounted for 30% of all new cancer cases in 2003-2005. This is marginally higher than the Manitoba average for this cancer at 29% Table4.15FemaleCancerIncidence/100,00020002002and20032005bySite(Age Adjusted) Breast Assiniboine Manitoba 20002002 20032005 20002002 20032005 116.0 128.0 123.0 122.0 Cervical 7.0 9.0 9.0 9.0 Colorectal 71.0 46.0 55.0 52.0 Lung 57.0 47.0 60.0 63.0 Melanoma 15.0 11.0 10.0 9.0 436.5 422.8 434.3 427.1 ALL SOURCE:CANCERCAREMB2009 RadiationTreatmentUtilization During the community engagement meetings, community members spoke about the need for radiation treatment closer to home. Currently, residents of the Assiniboine region who require radiation treatment must travel to Winnipeg. This can create hardship for many due to the costs of travel, accommodation, possibly time away from work, and separation from support networks such as family and friends. Clients have mentioned that the staff with CancerCare in Winnipeg are very accommodating for clients who must travel long distances for treatment, and will schedule treatments to allow clients to spend as much time at home as possible (e.g., scheduling treatments later on Mondays and earlier on Fridays). There are services that assist people receiving chemotherapy or radiation therapy with accommodation (Lennox Bell Lodge) and transportation (Canadian Cancer Society Volunteer Driver program). Construction is currently underway on a new cancer treatment centre in Brandon. The establishment of this centre, which will be the first site outside of Winnipeg to offer radiation therapy, will offer Assiniboine residents the option of obtaining treatment much closer to home. According to their website, Brandon RHA expects the construction to be completed in late 2010 and that services will be available in the spring of 2011. PG:112CHAPTER4:BURDENOFILLNESS CancerSurvivalRate The 5-year post diagnosis survival rates (the percentage of people still alive five years after their diagnosis of cancer) for both males and females for all cancers are almost identical to the provincial averages and for 2000-2004 are 60% for females and 59% for males. For individual cancer sites the data is not currently available at a regional level but for the Rural South, the highest rate of survival for females is for breast cancer at 86% and the lowest for lung cancer at 23%. For males the highest is for prostate cancer at 92% and the lowest for lung cancer at just 16%. Table4.165YearRelativeCancerSurvival19951999and20002004 SouthEastman Female Male 19951999 20002004 19951999 20002004 59% 65% 58% 65% Central 57% 57% 60% 61% Assiniboine 58% 58% 61% 60% Brandon 57% 61% 63% 64% Winnipeg 55% 56% 59% 58% Interlake 54% 57% 54% 60% NorthEastman 52% 56% 56% 62% Parkland 53% 56% 56% 56% NorMan 58% 52% 55% 57% Burntwood 49% 51% 58% 51% Manitoba 56% 57% 59% 59% SOURCE:CANCERCAREMB2009 CancerMortality In both males and females, lung cancer is the leading cause of death by cancer in the Rural South region with 21.7% of all female deaths due to cancer and 27.2% of all male deaths due to cancer attributed to it in the period 2000-2005. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:113 BreastCancerScreening Screening mammography is used to detect early breast cancer in women at increased risk because of their age. In Manitoba, it is recommended that screening mammography be offered every two years to all women 50 to 69 years of age (although it may be offered to younger women based on a positive family history of breast cancer). The proportion of the region’s women receiving at least one mammogram (screening or diagnostic) in the two year period 2004/05-2005/06 was 66.4%. This compares with a Manitoba average of 61.7% for the same time period. This rate is virtually unchanged for Manitoba from 1999/00-2000/01 when it stood at 61.4% but the region’s rate has dropped slightly from 68.4% in 1999/00-2000/01. There is very little district level variation in the region other than in East 2 where a significantly higher rate of 71.2% can be found. Figure4.15MammographyRatesforWomenAged5069,1999/002000/01and 2004/052005/06(Ageadjusted) 1999/002000/01 2004/052005/06 MBAvg1999/002000/01 MBAvg2004/052005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0% 10% 20% 30% 40% 50% 60% 70% 80% SOURCE:MCHPRHAINDICATORSATLAS2009 PG:114CHAPTER4:BURDENOFILLNESS More recent data from 2006/07-2007/08 (crude values) shows an overall increasing trend in the rate of residents undergoing a mammogram with particularly high values in the southeast corner of the region (districts East 2 and West 1). The rate for First Nation residents is particularly low but showing some improvement. Table4.17MammographyRatesforWomenAged5069,2004/052005/06and 2006/072007/08(CrudeValues) 2004/052005/06 2006/072007/08 #Observed Rate #Observed Rate North1 902 65.3% 991 68.6% North2 769 62.6% 817 64.5% East1 783 65.2% 812 63.6% East2 1056 70.7% 1115 72.5% West1 712 67.0% 812 71.4% West2 1,000 50 5222 62.9% 29.4% 65.6% 1126 84 5673 67.5% 47.5% 68.1% FNReserves Assiniboine SOURCE:MBHEALTHHIMBRANCH2009 CervicalCancerScreening Pap (Papanicolauo) testing is a screen for cervical cancer and is recommended once every three years for women aged 18 to 69 years. Pap testing is one of the most successful cancer screening tools and if the screen is performed regularly, it detects up to 90 per cent of cervical cancers early in their development. Treatment at this early stage is usually effective. Assiniboine Pap test rates are significantly lower than the Manitoba average at 63.8% in the three year period 2003/04-2005/06 compared to 69.2%. Rates are particularly low in the North 1 and East 2 districts of the region. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:115 Figure4.16‘Pap’TestRatesforWomenAged1869,1998/992000/01and2003/04 2005/06(Ageadjusted) 1998/992000/01 2003/042005/06 MBAvg1998/992000/01 MBAvg2003/042005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0% 10% 20% 30% 40% 50% 60% 70% 80% SOURCE:MCHPRHAINDICATORSATLAS2009 More recent data from 2005/06-2007/08 (crude values) shows fairly static rates across the region for Pap testing. There are however very low rates amongst both First Nation residents and the residents of the North 1 district which have shown no improvement from their 2003/04-2005/06 values. PG:116CHAPTER4:BURDENOFILLNESS Table4.18‘Pap’TestRatesforWomenAged1569,2003/042005/06and2005/06 2007/08(CrudeValues) 2003/042005/06 2005/062007/08 #Observed Rate #Observed Rate North1 1968 49.1% 1811 45.5% North2 1989 61.0% 2018 62.0% East1 2135 61.2% 2266 65.2% East2 2337 55.9% 2402 58.1% West1 1816 60.7% 1877 62.3% West2 2746 399 12991 57.9% 46.2% 57.3% 2727 377 13101 58.2% 43.5% 58.1% FNReserves Assiniboine SOURCE:MBHEALTHHIMBRANCH2009 ColorectalCancerScreening Colorectal cancer (also called colon cancer or large bowel cancer) includes cancerous growths in the colon, rectum, and appendix. It has the third highest incidence amongst both male and female residents of the region. Screening for colorectal cancer can start with a fecal occult blood test (FOBT), a test which checks for blood in the stool which are readily available and can be used in the home. A positive test will normally lead to further investigation in the form of a colonoscopy. There is a provincial colorectal screening program called ColonCheck. The goals of this program, which was initiated in 2007 as the Manitoba Colorectal Cancer Screening program, is to help detect colorectal cancer early and to reduce the number of Manitobans who die from the disease. The Assiniboine region was a partner in the first phase roll-out with the Manitoba Colorectal Cancer Screening program to improve colorectal screening rates. Through the project, eligible residents received a screening kit in the mail along with information about colorectal screening. The project has also aimed to improve physician awareness of colorectal screening. Just fewer than 16% of the Assiniboine residents who received the test kits participated in the screening project. Of those, 3.5% had a positive screening result. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:117 Mortality Mortality rates or death rates have been used frequently as indicators of the health of a population. These rates can provide information about the causes of death in a population as well as how long people are living. TotalMortalityRate Total mortality rate (TMR) is a simple measure of the number of deaths per 1,000 residents, per year. The age and sex adjusted rate of mortality for the Assiniboine region for the period 2001-2005 was 7.68 which is slightly lower than that for 1996-2000 when it was 7.77. These rates are not significantly different from the provincial average values which were 7.99 and 8.37 in the same time periods. There is very little district level variation in these rates other than in East 2 which has a generally lower TMR. The population demographics of the region (a large proportion of elderly residents) mean that the crude rates are considerably higher at 11.41 and 11.40, second only to the Parkland RHA. CausesofDeath The top three causes of death in the Assiniboine region are the same for both males and females and account for 67% of all deaths in the region. Diseases of the circulatory system (the heart, the blood, and blood vessels) are the leading cause of death in the region, accounting for a third of all deaths in the period 2002-2006, although these appear to be declining from previous much higher values in past years. Neoplasms or cancers are the second leading cause of death accounting for 26% of all deaths in both males and females. Diseases of the respiratory system (airways and lungs) are the third leading cause of death accounting for around 9% of all female deaths and 10% of all male deaths. These also appear to be declining in more recent years. PG:118CHAPTER4:BURDENOFILLNESS For females the next two leading causes of death are diseases of the endocrine/nutritional system and diseases of the nervous system. These both appear to be increasing in recent years. Figure4.17Top5FemaleCausesofDeathforARHAResidents19921996,19972001, 20022006 19921996 19972001 20022006 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Circulatory Neoplasms Respiratory Endoc./Nutritional Nervoussystem AllOtherCauses SOURCE:VITALSTATISTICS2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:119 For males the fourth leading cause of death is death due to external causes which is primarily injuries. These accounted for more than 8% of male deaths in the period 2002-2006 and along with deaths from diseases of the endocrine/nutritional system appear to be on the rise. The leading causes of death for both males and females in the region are consistent with those in Manitoba as a whole. Figure4.18Top5MaleCausesofDeathforARHAresidents19921996,19972001, 20022006 19921996 19972001 20022006 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Circulatory Neoplasms Respiratory ExtCauses Endoc./Nutritional AllOtherCauses SOURCE:VITALSTATISTICS2009 PG:120CHAPTER4:BURDENOFILLNESS UnintentionalInjuryDeaths Deaths due to unintentional (“accidental”) injuries include deaths due to causes such as motor vehicle collisions, falls, drowning, burns, and poisoning. In the five year period 2002-2006, the rate of unintentional injury death in the region has remained consistently higher than the Manitoba average for males and is generally increasing. For females the rate is not significantly different to the Manitoba average. Injury mortality is particularly high in the west of the region with the North 1 and West 2 districts showing the highest rates. Table4.19UnintentionalInjuryDeathrate/100,000,20022006(AgeAdjusted) Deathrate/100,000 2002 2003 2004 2005 2006 Assiniboine(Female) 43.7 23.3 23.6 26.2 30.1 Manitoba(Female) Assiniboine(Male) 27.8 46.2 26.4 51.1 30.0 56.5 28.0 66.0 33.2 59.6 Manitoba(Male) 39.3 38.1 43.6 41.2 41.5 SOURCE:VITALSTATISTICS2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:121 PrematureMortalityRate(PMR) The premature mortality rate (PMR) indicates the average annual rate at which residents died before reaching age 75. It is shown here per 1,000 residents under 75 and has been age and sex adjusted to the population of Manitoba. The premature mortality rate is considered the best single indicator of the overall health status of a region’s population and need for healthcare. PMR is correlated with morbidity and with self-rated health, as well as socioeconomic indicators. The region’s PMR is the third lowest in the province, behind only Central and South Eastman. It has decreased in recent years in line with Manitoba as a whole and is significantly below the Manitoba average. It is still, however, higher than the average for the Rural South. Figure4.19PrematureMortalityRates/1,000Residentsagedunder7519962005(Age andSexAdjusted) Arearate ManitobaAverage SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0 1 2 3 4 5 6 7 SOURCE:MCHPRHAINDICATORSATLAS2009 PG:122CHAPTER4:BURDENOFILLNESS There is considerable variation in PMR across the districts of the Assiniboine region with North 2 having the highest PMR and East 2 the lowest. Figure4.20PrematureMortalityRates/1,000Residentsagedunder75byARHA District19962005(AgeandSexAdjusted) Arearate ManitobaAverage RuralSouthAverage ASEast2 ASWest1 ASNorth1 ASWest2 ASEast1 ASNorth2 Assiniboine RuralSouth Manitoba 0 1 2 3 4 5 SOURCE:MCHPRHAINDICATORSATLAS2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:123 PMR values are much higher for males than for females; a result of the higher life expectancy values for females. It is interesting however to note that whilst all the districts have a female PMR lower than the Manitoba average for females, two districts North 1 and North 2 have male PMR rates higher than the Manitoba average for males suggesting that males in the north of the region have a lower health status in general. Figure4.21PrematureMortalityRates/1,000Residentsagedunder75byARHA DistrictbyGender19942003(AgeAdjusted) MalePMR FemalePMR MBAvg.Female MBAvg.Male ASEast2 ASWest1 ASNorth2 ASWest2 ASNorth1 ASEast1 Assiniboine RuralSouth Manitoba 0 1 2 3 4 5 SOURCE:MCHPSEXDIFFERENCESINHEALTH2005 PG:124CHAPTER4:BURDENOFILLNESS LifeExpectancy Life expectancy is a measure of the expected length of life from birth, based on the patterns of mortality population for the preceding five years. Values are calculated from the mortality experience of local residents using the ‘life table’ approach. A life table (also called a mortality table) is a table which shows, for each age, what the probability is that a person of that age will die before their next birthday. Life expectancy in the region for males is similar to the provincial average whilst that for females is significantly higher than the provincial average. The lowest life expectancy for males can be found in the North 1 district at 76.0 years whilst the lowest for females in the North 2 district at 81.1. The highest life expectancy for both males and females can be found in the East 2 district at 77.5 and 83.4 respectively. Given that life expectancy for registered First Nation people is reported to be almost ten years less than the average Manitoban, it is not surprising that the lowest life expectancies can be found in the areas with large Aboriginal communities. Table4.20LifeExpectancy19962000and20012005 Male Female 19962000 20012005 19962000 20012005 ASEast2 76.7 77.5 85.0 83.4 ASWest1 ASNorth1 ASWest2 77.2 74.4 75.4 77.3 76.0 75.6 81.6 83.7 82.7 82.7 82.3 82.8 ASEast1 75.7 76.3 81.2 82.9 ASNorth2 76.4 77.2 82.0 81.1 Assiniboine 75.8 76.5 82.7 82.4 RuralSouth 76.6 77.6 82.3 82.7 Manitoba 75.6 76.3 81.0 81.5 SOURCE:MCHPRHAINDICATORSATLAS2009 PotentialYearsofLifeLost(PYLL) When a person dies before the age of 75, their death is considered to be premature. It is possible to calculate the number of years of life that an individual has lost by subtracting their age at death from 75. When the potential years of life lost in a population is high compared to the number of people who have died prematurely, it is likely those people have died at a relatively young age. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:125 The PYLL rate per 1,000 residents in the region has increased from 47.8 in 1996-2000 to 54.3 in 2001-2005. This is in contrast to the rest of Manitoba where it has dropped slightly from 54.8 to 50.9 in the same time period. The East 2 district has shown the sharpest rise although only the North 1 district has shown any decline between 1996-2000 and 2001-2005. Figure4.22PotentialYearsofLifeLost(PYLL)per1,000Residentsaged1741996 2000and20012005(AgeandSexAdjusted) 19962000 20012005 MBAvg19962000 MBAvg20012005 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0 25 50 75 100 125 SOURCE:MCHPRHAINDICATORSATLAS2009 PG:126CHAPTER4:BURDENOFILLNESS Whilst the PYLL in females is expected to be considerably lower than for males because of their longer life expectancy, it is noticeable that in all but one district the PYLL rate for females is lower than the Manitoba average for females and in four of the six districts the PYLL rate for males is higher than the Manitoba average for males. This appears to be a common theme in the region. Figure4.23PotentialYearsofLifeLostbyGender19942003(AgeAdjusted) MalePYLL FemalePYLL MBAvg.Female MBAvg.Male ASEast2 ASWest1 ASNorth2 ASWest2 ASNorth1 ASEast1 Assiniboine RuralSouth Manitoba 0 25 50 75 100 SOURCE:MCHPSEXDIFFERENCESINHEALTH2005 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:127 PotentialYearsofLifeLost(PYLL)byCauseofDeath The highest value for PYLL amongst male residents of the region is for deaths due to suicide whilst for females it is respiratory disease. Table4.21PYLLper1,000ARHAResidents20022006(CrudeValues) Male Female Cancer 13.8 6.3 RespiratoryDisease CirculatoryDisease Injury 13.9 1.5 1.4 15.4 3.8 8.5 Suicide 14.9 2.7 SOURCE:MANITOBAHIMBRANCH2009 SuicidedeathsarediscussedinChapter8:MentalHealthandinfantmortalityin Chapter7:PublicHealth. PG:128CHAPTER4:BURDENOFILLNESS ChapterHighlights Male residents of the region are in general about as healthy as the average Manitoban male, whereas females are healthier than the average female Manitoban. Diseases of the circulatory system are still the leading causes of death in both men and women in the region. The region is developing strategies and protocols to improve quality of care and prevention activities for cardiovascular disease. The prevalence of stokes, heart attacks, ischemic heart disease, arthritis, and respiratory diseases have all decreased since the last CHA. The prevalence of diabetes, osteoporosis, and hypertension has all increased since the last CHA. Cardiac catheterization and cardiac revascularization intervention rates are increasing but are still amongst the lowest in the province. Stroke mortality is consistently higher the Manitoba average. There are very low rates of breast and cervical cancer screening amongst the population living on First Nation reserves. Community Cancer programs are increasing their scope of care in order to ease demands in larger centers. Prostate cancer rates remain high among men in the Assiniboine Region. Unintentional injury rates among males have been higher than Manitoba average and are increasing. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:129 Chapter5:PrimaryCare Primary care is generally considered the first point of contact when someone is seeking health care, most often through a physician or nurse, but may refer to other health care professionals as well. It includes the prevention, diagnosis, treatment, and follow-up of various health conditions. Primary care also includes referrals to specialists and diagnostic services such as lab tests or X-rays. Access to primary care providers was by far one of the most important health issues for community members. The ability to access primary care physicians was mentioned in every area. Community members discussed the length of time they must wait for an appointment to see a physician, as well as the availability of family physicians. The waiting time for appointments varies, depending on the physician practice and the urgency of the issue. Because some physicians are not able to accept new patients due to existing caseloads, it can be difficult for new residents, or those who do not currently have a family physician, to find one who can assume their care. Recruitment of physicians and nurses were high priorities for communities. A number of community members and staff have suggested that it would be valuable to use nurse practitioners to help lighten the load of physicians. PrimaryCareProgram The Assiniboine Regional Health Authority has established a Primary Care program whose focus is to assist in the delivery of health care services to clients who may have difficulties finding or accessing a health care provider or services. The program helps provide screening to clients, providers to those who need to access to one, education, and help to clients try to maintain as healthy a life as they can. The program consists of a team of primary care nurses working collaboratively with physicians within the region as well as a team of nurses trained to provide cervical screening to women accessing established clinics. Currently, the program has two sites staffed with full time primary care registered nurses with expanded duties through delegation of function and three sites are staffed with part time RN (EP) – nurse practitioners. The Rossburn and Erickson Primary Care Access sites are staffed with the registered nurses with delegation of function. Both of the Access sites deliver services on a full time basis- Monday to Friday. Both nurses work in conjunction with physicians at their respective sites. An Access Site Clinic is held every Friday at the Waywayseecappo First Nation Health Unit for residents of the community. The Hamiota, Wawanesa, and Carberry Primary Care Access sites and Neepawa personal care home (Country Meadows) are staffed with part time RN (EP) - nurse practitioners. Two of these Access sites provide service on a part time basis. PG:130CHAPTER5:PRIMARYCARE The use of the Electronic Primary Care Record has become one of the initiatives within the region. The electronic record is functioning at clinics with primary care nurses as well as other medical clinics that have shown interest and are willing to invest in converting their current practice into a paperless system. Currently, there are nine clinics on the same shared system with the Electronic Primary Care Record: Russell, Birtle, Hamiota, Souris/Hartney, Erickson, Treherne, and Rossburn (with access from Waywayseecappo), Wawanesa, and Virden clinics. We recognize that patients access health care services in neighbouring communities and are hopeful that the increased availability of medical information to specific health care providers throughout the region will improve continuity of care, lessen duplication of diagnostic tests or services, and result in better quality primary care services for all clients with the implementation of the Electronic Primary Care Record. The newest service the Primary Care program has been providing, in conjunction with RANA Medical Services, is provision of educational sessions on Chronic Obstructive Pulmonary Disease (COPD). Educational sessions include: An Introduction to COPD and Breathing Exercises, Recognizing and Understanding Symptoms, Understanding Medication for COPD, COPD and Healthy Living, and Exercise and COPD. Primary care nurses deliver the educational sessions at scheduled sites and answer any questions or concerns. Currently we provide these sessions with RANA in the communities of Russell, Minnedosa, and Neepawa. It is hoped to expand these educational sessions to other communities in the ARHA that RANA Medical visits. These sessions are open to clients and/or their families as well as the general public who wish to attend and learn about chronic lung disease. During community engagement activities prior to the establishment of the Primary Care program, community members stated that one of the barriers to accessing cervical and breast screening was lack of female providers. Women stated they felt more comfortable going to a female provider for these types of exams. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:131 Through the Primary Care program, Women’s Wellness Clinic nurses now hold screening clinics for women in different communities across the ARHA. The Women’s Wellness Clinics allow women to get cervical screening and/or a clinical breast examination completed by a trained female provider. Table5.1ARHAPrimaryCareClinicsandScreensCompleted04/200808/2009 2008 2009 NumberofScreens NumberofClinics APR 46 5 MAY 54 8 JUN 87 12 JUL 14 2 AUG 11 1 SEP 37 6 OCT 144 14 NOV 45 6 DEC 20 5 JAN 25 5 FEB 27 3 MAR 38 8 APR 39 5 MAY 43 6 JUN 59 8 JUL 30 5 AUG 21 4 SOURCE:ARHAPRIMARYCAREPROGRAM2009 PhysicianUse The physician is viewed by community members as the cornerstone of the health care system. Access to primary care physicians is one of the most predominant themes from the community engagement meetings. As mentioned earlier, community members were concerned about access to physicians. Rural communities have faced challenges in physician supply for over a decade. This is being influenced by changing demographics in our communities and the practice patterns and preferences of new physicians. The long working hours and varied skills required for rural practice can be very demanding. In smaller physician practices, a doctor may be required to be on call every other night and every other weekend. This is not appealing to many newly graduated physicians. PG:132CHAPTER5:PRIMARYCARE Physician recruitment efforts in the Assiniboine region are ongoing. In recent years, most of the physicians who have come to the region are from foreign countries. Unfortunately, and for a number of reasons, some of them move on after a few years. The Assiniboine region has an ongoing relationship with the University of Manitoba Faculty of Medicine through the Rural Week event, in which medical students are introduced to rural practice, and participate in the Family Medicine resident training program. A visit to a physician or ‘ambulatory visit’ includes almost all contacts with physicians but excludes services to residents while admitted to a hospital. For Brandon and the Rural South, the top ten reasons for physician visits are fairly well defined and have changed little from 2000/2001 to 2005/2006 with respiratory and circulatory issues remaining the top two reasons. The pattern remains consistent across Manitoba as a whole. Figure5.1PhysicianVisitsbyCauseBrandonandRuralSouth 100% 90% 80% 70% 60% OTHER,18.6% OTHER,20.1% DISORDERSOFSKIN,5.2% ENDOCRINE& METABOLISM,5.7% MENTALILLNESS,6.0% GENITOURINARY&BREAST, 5.9% GENITOURINARY&BREAST, 6.4% HEALTHSTATUS& CONTACT,7.0% INJURY&POISON,6.6% MENTALILLNESS,6.7% INJURY&POISON,7.3% NERVOUSSYSTEM,7.6% 50% NERVOUSSYSTEM,8.2% HEALTHSTATUS& CONTACT,7.8% 40% MUSCULOSKELETAL,8.6% 30% 20% ILLDEFINED,9.0% CIRCULATORY,9.7% ILLDEFINED,8.6% MUSCULOSKELETAL,9.0% CIRCULATORY,9.7% 10% RESPIRATORY,14.1% RESPIRATORY,12.3% RuralSouth&Brandon2000/01 RURALSOUTHANDBRANDON2000/01 RuralSouth&Brandon RURALSOUTHANDBRANDON2005/06 0% SOURCE:MCHPRHAINDICATORSATLAS2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:133 The use of physicians in the Assiniboine region is comparable to that in the rest of Manitoba with 87% of females and 77% of males who had at least one ambulatory visit to a physician in the fiscal year 2003/04. There was however, a significantly lower ambulatory visit rate amongst both males and females in the East 2 district of the region. Physician visit rates are highest amongst females, the very young, and the older residents of the region, and there is a significant relationship between physician use and area-level income with a higher proportion of residents from higher income areas visiting physicians. TheAssiniboineRegionalHealthAuthority’srelativelyhigh(andprojected to increase substantially) dependency ratio is likely to have a significant impactonphysicianuseintheregionintheyearstocome. DependencyRatio–SeeChapter1:Population Figure5.2PhysicianUsebySex2003/2004(AgeAdjusted) Males Females MBavgmales MBavgfemales SouthEastman Central Assiniboine Brandon Parkland Interlake NorthEastman Churchill NorMan Burntwood RuralSouth North Winnipeg Manitoba 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% SOURCE:MCHPSEXDIFFERENCESINHEALTH2005 PG:134CHAPTER5:PRIMARYCARE AmbulatoryVisitRates Ambulatory visit rates are the average number of visits to physicians per resident per year. They include almost all contacts with physicians including office visits, walk-in clinics, home visits, nursing home visits, and visits to outpatient departments, but exclude services provided to patients while admitted to a hospital and visits for prenatal care. The ambulatory visit rate for the region was 4.51 in 2005/06, down from the 2000/01 value of 4.74. The rate is significantly lower than the Manitoba average of 4.99 for 2005/06 which is heavily influenced by much higher rates in the urban centres of Brandon and Winnipeg. It is however comparable with the Rural South rate of 4.42 for 2005/06. District rates are very similar across the region, other than in the West 1 district, where the rates is very high at 5.81 for 2005/06. Figure5.3AmbulatoryVisitRates2000/2001and2005/2006(AgeandSexAdjusted) 2000/01 2005/06 MBAvg2000/01 MBAvg2005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood RuralSouth Mid North Manitoba 0 1 2 3 4 5 SOURCE:MCHPRHAINDICATORSATLAS2009 6 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:135 In crude numbers, the drop in the ambulatory visit rate between 2000/01 (347,940 visits) and 2005/06 (315,605 visits) constitutes over 32,000 less physician visits. Female residents, and those from higher income rural areas, are more likely to have higher ambulatory visit rates than male residents and those from lower income rural areas. This is contrary to what might be expected given the higher burden of illness associated with low income areas. LocationofVisitstoGeneralandFamilyPractitioners(GP/FP) The location of visits made by residents to general and family practitioners is shown in the following table. It lists the proportion of those that were within the district of residence, those made elsewhere in the RHA, those made to another RHA, and those to Winnipeg. Table5.2LocationofVisitstoGP/FP2000/01and2005/06 %InDistrict %Elsewherein RHA %ToOtherRHA %ToWinnipeg East200/01 67.2% 5.7% 20.8% 6.3% East205/06 65.7% 6.8% 24.2% 3.4% West100/01 76.7% 8.2% 13.5% 1.6% West105/06 73.0% 8.5% 17.1% 1.4% North100/01 86.1% 3.4% 8.3% 2.2% North105/06 82.3% 4.4% 10.8% 2.4% West200/01 71.1% 10.8% 16.2% 1.9% West205/06 67.7% 10.0% 20.7% 1.7% East100/01 81.3% 3.1% 13.2% 2.4% East105/06 84.5% 2.2% 11.0% 2.3% North200/01 67.5% 16.1% 13.5% 2.9% North205/06 60.4% 16.4% 20.2% 3.0% Assiniboine00/01 75.3% 7.7% 14.1% 2.9% Assiniboine05/06 72.5% 7.8% 17.3% 2.3% RuralSouth00/01 68.1% 11.1% 7.8% 13.1% RuralSouth05/06 66.7% 12.3% 8.5% 12.6% Manitoba00/01 85.8% 4.2% 3.9% 6.1% Manitoba05/06 85.6% 4.4% 4.1% 5.9% SOURCE:MCHPRHAINDICATORSATLAS2009 When compared to the Rural South, Assiniboine residents are more likely to visit a GP/FP within their district of residence (72.5% in 2005/2006 vs. 66.7%), particularly, those in the North 1 and East 1 districts of the region. Predictably, the percentage of PG:136CHAPTER5:PRIMARYCARE residents seeking treatment in another RHA (predominantly Brandon) is relatively high at 17.3% particularly in the East 2 district (almost a quarter of visits at 24.2% in 2005/06). The North 2 district shows a high percentage of residents seeking treatment in another district (16.4% in 2005/06). AmbulatoryConsultationRates Ambulatory ‘consultations’ are a subset of ambulatory visits which occur when one physician refers a patient to another physician (usually a specialist or surgeon) because of the complexity, obscurity, or seriousness of the condition. The ambulatory consultation rate in the region (0.197 for 2005/2006) is significantly below the Manitoba average (0.274 for 2005/2006) and has dropped significantly from the 2000/20001 value of 0.239. It is an indication that the region’s access to, and utilization of, specialist care (as can be seen later in this chapter) is amongst the lowest in the province. Figure5.4AmbulatoryConsultationRateperResident2000/01and2005/06(Ageand SexAdjusted) 2000/01 2005/06 MBAvg2000/01 MBAvg2005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland 0.49 Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0.00 0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.40 0.45 0.50 SOURCE:MCHPRHAINDICATORSATLAS2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:137 ContinuityofCare Continuity of care, the lasting relationship between a patient and a physician, is one of the defining principles of family medicine. It is mainly viewed as the relationship between a single practitioner and a patient that extends beyond specific episodes of illness or disease. It is thought to foster improved communication, greater trust, and a sustained sense of responsibility, leading ultimately to improved health outcomes. Figure5.5ContinuityofCareRates1999/002000/01and2004/052005/06(Ageand SexAdjusted) 1999/002000/01 2004/052005/06 MBAvg1999/20002000/01 MBAvg2004/052005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% SOURCE:MCHPRHAINDICATORSATLAS2009 The continuity of care rate for the region (the percentage of residents receiving at least 50% of their ambulatory visits over a two year period from the same physician) was 61.5% in 2004/05-2005/06, a slight increase from the 1999/00-2000/01 value of 59.0%. These rates are significantly below the Manitoba averages of 67.7% and 65.7% for the same time periods, but much closer to the Rural South averages of 61.3% and 61.0%. PG:138CHAPTER5:PRIMARYCARE AmbulatoryVisitRatetoSpecialists Community members expressed concern about access to specialists. Because there are no specialists in the Assiniboine Region, it is necessary for residents to travel to either Brandon or Winnipeg to access care from a specialist. Waiting times for appointments with specialists in Brandon may be extremely long. Staff felt that it would be helpful to have a list of specialists as a resource for physicians, particularly those who are new to the country and to our health system. Ambulatory visit rates to specialists are the average number of visits made to specialist physicians per resident per year. Specialist physicians include all internal medicine specialists, pediatricians, psychiatrists, obstetricians/gynaecologists, and surgeons. Lack of transportation may be a barrier for the people who are in most need of specialist care. Other reasons discussed by staff were; aging population, waiting list, resources, and volume of clients to be seen. The specialist visit rate in the Assiniboine region is considerably lower than both that in Manitoba (1.27), and the Rural South (0.64), and has declined slightly from 0.55 in 2000/01 to 0.51 in 2005/06, a trend that is not repeated in any other region other than Brandon. Specialist visit rates are particularly low in those districts of the region furthest away from Winnipeg, i.e. the North 1 and West 2 districts. Female residents and those from higher income rural areas are more likely to have higher specialist visit rates than male residents and those from lower income rural areas. This is contrary to what might be expected given the higher burden of illness associated with low income areas. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:139 Figure5.6AmbulatoryVisitRatestoSpecialists2000/2001and2005/2006(Ageand SexAdjusted) 2000/01 2005/06 MBAvg2000/01 MBAvg2005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood RuralSouth Mid North Manitoba 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 SOURCE:MCHPRHAINDICATORSATLAS2009 1.8 PG:140CHAPTER5:PRIMARYCARE LocationofVisitstoSpecialists The location of visits made by residents to specialists is shown in the following table. It lists the proportion of those that were within the district of residence, those made elsewhere in the RHA, those made to another RHA, and those to Winnipeg. Table5.3LocationofVisitstoSpecialists2000/01and2005/06 %InDistrict %Elsewherein RHA %ToOtherRHA %ToWinnipeg East200/01 0.1% 0.1% 54.9% 44.9% East205/06 . . 50.4% 49.6% West100/01 . 0.1% 73.9% 26.0% West105/06 . . 65.3% 34.7% North100/01 . 0.1% 61.8% 38.1% North105/06 . . 50.1% 49.9% West200/01 . 0.2% 72.9% 26.9% West205/06 . . 62.5% 37.5% East100/01 0.3% 0.1% 54.9% 44.8% East105/06 . . 46.9% 53.1% North200/01 . 0.1% 63.6% 36.3% North205/06 . . 51.3% 48.7% Assiniboine00/01 0.10% 0.10% 63.70% 36.2% Assiniboine05/06 0.00% 0.00% 54.40% 45.6% RuralSouth00/01 7.10% 2.40% 19.60% 70.90% RuralSouth05/06 6.70% 3.10% 14.10% 76.10% Manitoba00/01 79.60% 0.60% 2.50% 17.30% Manitoba05/06 78.20% 0.80% 2.00% 18.90% SOURCE:MCHPRHAINDICATORSATLAS2009 Visits to specialists are predominantly to Brandon and Winnipeg (where most are located), however the trend over time has been for fewer visits to Brandon and more residents visiting specialists in Winnipeg (45.6% in 2005/06 compared to 36.2% in 2000/01). ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:141 MBTelehealth MB Telehealth is a network that enables residents of Manitoba and surrounding areas to receive comprehensive health care services while overcoming barriers of distance and time through the use of technology. A satellite or ground link is used to connect a specialist or other health care provider to a patient in the region. The patient is able to see, hear, and talk to the health care provider (on a television screen) who is also able to see, hear, and talk to the patient. Examples of specialties involved include: dermatology, diabetes education, mental health, cardiology, enterostomal therapy (a specialized field of nursing involving the care of patients with stomas, incontinence, dermal ulcers, and other select skin conditions or those needing wound care), oncology, general surgery, anaesthesia, and psychiatry. Using Telehealth has several benefits when compared to visiting the health care provider in person. It decreases the time spent away from home and work, saves time, money, and the risks associated with travel, and can improve access to specialized services that are not currently available in the region. Community and staff recognize the value of Telehealth, particularly for short follow-up visits. Some providers mentioned that it can be difficult to assess a client through Telehealth. Some partners felt that Telehealth may not be the best option in a few situations. There are currently six Telehealth sites spread across the Assiniboine region which enable residents to interact with specialists in their local or surrounding communities and prevent the need for travel to either Brandon or Winnipeg. The facilities currently hosting Telehealth are Killarney, Russell, Neepawa, and a recent expansion has added Deloraine, Virden, and Hamiota. Telehealth usage has shown a steady increase in the region from its introduction in 2002/2003 and there were 640 separate events in the 2008/2009 fiscal year. This is expected to increase markedly in the next year with the introduction of the three new Telehealth sites. PG:142CHAPTER5:PRIMARYCARE Figure5.7RegionalTelehealthEvents2002/032008/09 KILLARNEY RUSSELL NEEPAWA 700 114 600 500 400 347 . 4 300 255 200 93 169 172 100 31 209 212 162 152 0 344 115 109 35 66 245 284 281 417 556 640 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 SOURCE:MANITOBATELEHEALTH2009 HealthLinksInfoSanté Health Links - Info Santé is a provincial program providing quality primary health care to Manitobans via the telephone 24 hours a day, seven days a week, in more than 110 languages. The phones are staffed by registered nurses with the knowledge to provide answers over the phone to health care questions and to guide individuals to the care that they need by referring them to other health care providers. Use of this service in the region is relatively low at just 3.3% of residents contacting Health Links at least once in the two year period 2004/05-2005/06, compared to a Manitoba average of 11.0% and a Rural South average of 6.2%. Call volumes have remained relatively stable between 2005 and 2009 for the region and are predominantly from females (6.8:1 on average). The reasons for these calls are varied and wide-ranging, but some of the more popular ones are abdominal pains, pediatric fever or vomiting, and post operative problems. Health Links estimates that it has prevented almost one hundred emergency room visits in the region between 2005 and 2009. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:143 Community members at the community engagement meetings were not always aware of the Health Links service. It was suggested that the service could be promoted through public awareness activities such as distribution of promotional information on fridge magnets. Some community members said that they had tried to use the service years ago and the waiting time was prohibitive. The service has increased its capacity in recent years. Table5.4ARHAHealthLinksCallVolumesbyGender20052009 Jan05Mar05 TotalFemale Calls 413 TotalMale Calls 71 SexNot Recorded 1 Quarterly Totals 485 Apr05Jun05 384 49 15 448 Jul05Sep05 395 69 11 475 Oct05Dec05 388 60 0 448 Jan06Mar06 364 52 0 416 Apr06Jun06 342 50 0 392 Jul06Sep06 395 59 0 454 Oct06Dec06 359 56 4 419 Jan07Mar07 385 60 2 447 Apr07Jun07 392 52 2 446 Jul07Sep07 428 63 36 527 Oct07Dec07 428 62 54 544 Jan08Mar08 409 49 50 508 Apr08Jun08 371 49 42 462 Jul08Sep08 343 53 60 456 Oct08Dec08 375 47 61 483 Jan09Mar09 407 64 68 539 Apr09Jun09 372 56 91 519 SOURCE:HEALTHLINKSINFOSANTÉ2009 PG:144CHAPTER5:PRIMARYCARE ChapterHighlights Access to primary care providers, specifically physicians, was one of the most significant concerns among community members. The Primary Care program has been well received by community. There is great interest in the Women’s Wellness Clinics offered across the region. Women, the very young, and elderly residents tend to have the highest use of physicians. Assiniboine residents continue to have a lower use of specialists than other Manitobans. There is a growing use of Telehealth services, which can reduce barriers to accessing some types of health care. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:145 Chapter6:PreHospitalandHospitalBasedCare EmergencyMedicalServices The Emergency Medical Services (EMS) program provides ambulance service to residents of the Assiniboine region. Residents pay to use the service if they do not have coverage through insurance, because this service is generally not considered an insured service under Medicare. In most cases, an inter-facility transfer between designated facilities will be covered for Manitoba residents if the transfer is considered medically necessary, however there are some exceptions. The Assiniboine region has launched public awareness campaigns to assist people to understand the costs of this service. The Assiniboine region has 25 EMS stations spread across the region with a total of 229 full-time, part-time, and casual staff responding to emergency calls and performing interfacility transfers on a daily basis. Call volumes have steadily increased over the past six years to 6,966 in 2009, a 44% increase from 2004. The proportion of primary calls to inter-facility transfers has remained steady at close to 50:50. Figure6.1EMSCallVolumes20042009PrimaryandIFT PrimaryCalls InterFacilityTransfers 4000 3500 3491 3360 3000 3318 3548 3418 3071 2878 2867 2500 2465 2551 2571 2624 2000 1500 1000 500 0 2004 2005 2006 2007 2008 2009 SOURCE:ARHAEMS2010 PG:146CHAPTER6:PREHOSPITALANDHOSPITALBASEDCARE EMS staff indicate that they often care for people with chronic lung disease, cardiac conditions, strokes, substance abuse, and falls among the elderly. EMS providers stated that they are seeing more people with strokes and heart attacks at younger ages. The EMS program has established strong links with other agencies, such as fire services, RCMP, and crisis management services. EMS staff also indicated that they have good working relationships with staff in emergency/acute care and long term care. One area that could be improved, according to EMS staff, is the transfer of information between providers. Community members in some areas expressed concern about the availability of EMS service in their communities. The EMS program relies heavily on casual staff. Currently 79% of the staff providing EMS service are employed on a casual basis, while the remaining providers have full time or part time positions. Many casual EMS staff have other jobs and may work with the EMS program as a service to their community. This could limit the hours that a casual EMS provider is available to be on call. Despite staffing issues causing some ‘out of service’ occurrences at many stations, EMS in the region has managed to maintain an impressive service with 93% of primary calls meeting the benchmark of less than 30 minutes from the time of the call to arriving on scene in the last three years. Staffing issues have been caused partly by the introduction of new educational standards, which have considerable implications for the region’s predominantly casual and part-time EMS staff. The EMTech course is the minimum educational requirement for employees in smaller EMS services. This training is being offered in the region through traditional classroom training and web-based educational programming with integrated classroom sessions in an effort to support staff training requirements. In early 2008, 19 students completed EMTech training through a traditional classroom session, while 7 students completed training through a web based session. The February to June 2008 class had an enrolment of 10 students for traditional classroom learning. A session held from September 2009 to February 2010 had 16 students enrolled; 8 in web based training and 8 in traditional classroom. The new minimum educational standard for paramedics is Primary Care Paramedic (PCP). This new standard does pose some challenges in many regions due to accessibility challenges for training programs and the intensive workload of the course. Some students are able to access PCP training in Saskatchewan or through private education providers in addition to that offered by Red River Community College in Winnipeg, but opportunities may be limited. The Assiniboine region was one of the 3 rural locations selected to deliver the Red River Community College training program in 2008. The Rural PCP training program was offered in Souris in 2008, but because the training is rotated through rural regions, it may be three or four years before it is offered in this region again. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:147 Due to a shortage of adequately trained EMS providers, EMS positions may be filled by hiring individuals who do not meet the posted qualifications. It is not uncommon to post for permanent part time EMS positions and receive no applicants. This results in an increasing dependence on RN escorts at a time when the nursing resources are also stretched. In addition, the responsibility for obtaining EMS licensure has transferred from the employer to the EMS personnel themselves. Completing the licensure process is generally achievable for full or part time EMS staff but can be a challenge for casual staff who may be working at other jobs. Even though there have been human resource challenges, the EMS program has remained committed to several injury prevention initiatives. A pilot project, the Home Health and Safety Check, was developed in conjunction with a Primary Health Care project several years ago. The Home Health and Safety Check involves a home inspection to identify safety hazards, especially those that could lead to falls, which are a leading cause of injury and death among residents of the region. The EMS staff have also been involved in Progressive Farm Safety Day Camps, bicycle helmet promotion, the PARTY (Preventing Alcohol & Risk-related Trauma in Youth) program, car seat inspections, seat belt promotion, and emergency preparedness activities. PG:148CHAPTER6:PREHOSPITALANDHOSPITALBASEDCARE HospitalBasedCare Acute care is treatment in which a patient is treated for a brief but severe episode of illness or injury. Care/treatment is administered with the goal of discharging the patient as soon as the patient is deemed healthy and stable, with appropriate discharge instructions. In the region, acute care centres provide constant care to ill or injured individuals for observation, diagnosis, treatment, or care. All of the acute care facilities provide nursing care and medical services. There was some interest expressed by staff and community in exploring opportunities to create “centres of excellence”. Community members were most concerned with the availability of acute care in hospitals and emergency services in their communities. A shortage of physicians has caused several hospitals to change the type of services they can safely provide. Nursing and diagnostic resource challenges can also create difficulty with maintaining existing levels of service. At the time of writing, the following facilities were offering acute care: Boissevain, Carberry, Deloraine, Glenboro, Hamiota, Killarney, Melita, Minnedosa, Neepawa, Russell, Shoal Lake, Souris, Treherne, and Virden. In some cases, when physician recruitment efforts to a community are not successful, it has been necessary to implement a nurse-managed care model in a facility. For the time that the nurse-managed care model is in place, that facility can provide transition care, which is care to patients who are medically stable that do not require 24 hours per day, 7 days per week medical (physician) supervision and/or intervention. This may include waiting for personal care home (PCH) placement, respite care, convalescent care, and palliative care. The goal is to provide a safe, more home-like environment within a facility, which is an interim measure. Staff indicate that in transition care they are trying to meet local needs with basic rehabilitation, convalescence, accommodating long stays without taking up acute hospital beds, and providing procedures locally, such as IV antibiotics and dressing changes. Staff report that transition care provides an important service that allows for greater capacity in the remaining acute care facilities. At the time of writing, the following facilities were offering transition care services: Baldur, Birtle, Erickson, Reston, Rossburn, and Wawanesa. Staff felt that having social workers available would assist with discharge planning. They also stated that having more home care staff available to continue care at home may help people to move through the system more quickly. The ongoing human resource challenges in hospitals require constant vigilance to ensure that there is adequate staffing to maintain safe services, particularly during holiday times ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:149 such as Christmas and summer vacation. Staff identified unpredictable shifts in service due to sudden human resource shortages as a challenge. Intensive recruitment efforts have been ongoing for a number of years in an effort to provide adequate staffing for the facilities in the Assiniboine region. It can be difficult however, to attract physicians and nurses to small rural facilities which require a wide range of skills but may have minimal professional support. Community members proposed many ideas for recruitment of health care providers, with training of local youth mentioned often. Some community members also proposed alternate models of providing hospital and physician services. It was generally recognized that this is not an isolated situation affecting only one community, but many communities in the Assiniboine and most rural regions are facing similar challenges The Assiniboine region participated in a recruitment mission to the Philippines in November of 2008. The goals of the mission were to reduce nursing vacancies and avoid disruptions in acute care and personal care home services. As a result of this mission, 35 registered nurses were recruited to the Assiniboine region. This mission was a partnership that involved communities, provincial partners, and international linkages. The nurses were provided with an intensive orientation and assistance with completing provincial licensing requirements. Communities have been instrumental in welcoming the nurses to their new home. PG:150CHAPTER6:PREHOSPITALANDHOSPITALBASEDCARE InfrastructureandUtilization The region has 20 acute/transitional care units ranging in age of construction from 1955 to 2000 with 366 beds (April 2009) offering various levels of care and services including cancer care, surgery, rehabilitation, transitional and palliative care. The region has the highest rate of operational acute/transitional care beds (more than 5) per 1,000 residents outside of Brandon in the province. Figure6.2OperationalHospitalBedsper1,000residents2001and2006(Acuteand Other) 2001 2006 MbAvg2001 MbAvg2006 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood RuralSouth Mid North Manitoba 0 1 2 3 4 5 6 SOURCE:MCHPRHAINDICATORSATLAS2009 The number of operational acute/transitional care beds per 1,000 residents has declined slightly from 2001-2006 and continues that trend in recent years down to almost 5/1,000 in 2008. The utilization of these beds varies from 27% to 83% and is predictably low in some facilities given the population served and services offered. The average occupancy over the past four years is 53% and has not varied considerably during that time frame. 7 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:151 Table6.1AcuteCareBedOccupancy20042008 MedicalDays LongTermStayDays RespiteDays TotalInpatientDays MaximumOccupancy Occupancy 20042005 20052006 20062007 20072008 53,639 17,934 914 72,487 135,415 53.5% 51,519 16,556 1,264 69,339 133,437 52.0% 50,387 13,329 891 64,607 125,560 51.5% 48,881 17,849 497 67,227 122,244 55.0% Average 20042008 51,107 16,417 892 68,415 129,164 53.0% SOURCE:ARHAMIS2009 HospitalSeparationRates A ‘hospital separation’ is any hospitalization for which a discharge abstract is created and includes all inpatient cases and day surgery cases. Age and sex adjusted hospital separation rates in the Assiniboine region (198/1,000 in 2000/01 and 173/1,000 in 2005/06) are significantly higher than Manitoba as a whole (150/1,000 in 2000/01 and 137 in 2005/06). The pattern is the same for separations of short duration stays (less than 14 days) but is not significantly different to the Manitoba average for long stays (greater than 14 days duration) in 2005/2006. The hospital separation rate for females is significantly higher than that of males, in common with Manitoba as a whole. There is a strong relationship between hospitalization rates and area-level income with higher rates among residents of lower-income areas corresponding to their higher illness burden and need for care. PG:152CHAPTER6:PREHOSPITALANDHOSPITALBASEDCARE Figure6.3HospitalSeparationRates/1,000(AgeandSexAdjusted) 2000/01 2005/06 MBAvg2000/01 MBAvg2005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0 50 100 150 200 250 300 350 SOURCE:MCHPRHAINDICATORSATLAS2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:153 The crude hospitalization rates (not age and sex adjusted) show an even greater disparity between the region and Manitoba as a whole, which is a reflection of the region’s greater proportion of older people who are considerably more likely to require some type of inpatient care. (19.3% of residents were 65 and over in June 2006 compared to only 13.6% in Manitoba as a whole). Table6.2CrudeHospitalSeparationRates2000/01and2005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba HospitalSeparations NumberObserved NumberObserved CrudeRate/1,000 CrudeRate/1,000 PerYear PerYear 2000/2001 2005/2006 7,678 141.1 7,458 123.5 16,679 172.2 15,813 156.3 15,718 219.7 13,644 199.1 7,612 160.8 7,337 149.1 82,440 127.0 75,515 114.0 11,812 157.6 11,289 147.0 6,103 155.0 6,213 155.3 9,703 220.8 9,353 221.7 218 216.3 152 158.8 4,659 184.6 4,237 173.8 8,903 197.6 10,319 223.5 40,075 179.9 36,915 160.5 27,618 174.5 26,855 168.9 13,780 193.3 14,708 205.7 172,679 149.9 162,447 138.2 SOURCE:MCHPRHAINDICATORSATLAS2009 PG:154CHAPTER6:PREHOSPITALANDHOSPITALBASEDCARE Hospital utilization amongst children in the region follows a similar pattern with hospital episode rates (an episode is defined as the complete hospitalization event in the sense that if a child was transferred between two hospitals in one stay it was only counted once) being significantly higher than the Manitoba average in the first time period (2000/2001) but not significantly different in the second time period (2005/2006). There was a significant decrease in the region’s rate between the two time periods from 62.1/1,000 to 46.6/1,000 in line with the rest of Manitoba. The crude hospital episode rates are very similar, given the fact that the region’s population structure in the 0-19 age group is very similar to that in Manitoba as a whole, with 25.7% of its population in that group in June 2005 compared to 26.6%. Although many children may visit the emergency rooms in Assiniboine acute care hospitals, the majority of admissions for children needing acute care occur in hospitals outside the region. Figure6.4HospitalEpisodeRates/1,000ResidentsAges019(AgeandSexAdjusted) 2000/01 2005/06 MBAvg2000/01 MBAvg2005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood South Mid North Manitoba 0 25 50 75 100 SOURCE:MCHPCHILDHEALTHATLAS2008 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:155 Almost 90% of the utilization of ARHA facilities is made up by residents of the Assiniboine RHA with just a very small proportion coming from other regional health authorities and from outside Manitoba. Figure6.5WhereARHAHospitalPatientsCameFrom:Separations20052006 RHAResidents ResidentsofOtherRHAs ResidentsofWinnipeg NonManitobans SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% SOURCE:MCHPRHAINDICATORSATLAS2009 100% PG:156CHAPTER6:PREHOSPITALANDHOSPITALBASEDCARE In contrast, less than 50% of hospital separations for our residents occurred in one of our facilities with 37% occurring in another RHA hospital (predominantly Brandon RHA), 13% in a Winnipeg hospital and 3% outside of Manitoba. Figure6.6WhereARHAResidentsWentforHospitalSeparations20052006 RHAHospital OtherRHAHospital WinnipegHospital OutofProvinceHospital SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% SOURCE:MCHPRHAINDICATORSATLAS2009 A comparison of hospital separations (one count per hospital admission) and hospital days (the length of time a client stays in hospital) indicates that the majority of longerterm stays for our residents occur within the region and that hospital separations outside the region are on the most part shorter in duration. This is indicated by the disparity that whilst only 47.7% of separations occur within the ARHA, these account for 65.8% of the hospital days used. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:157 Table6.3WhereARHAResidentsWentforHospitalSeparations/Days20052006 Separations/ Days 13,644 92,868 Separations Days ARHA Hospital 47.7% 65.8% OtherRHA Winnipeg 36.6% 24.5% 12.6% 7.4% Outof Province 3.0% 2.2% SOURCE:MCHPRHAINDICATORSATLAS2009 Table6.4WhereARHAFacilityClientsCameFromforHospitalSeparations/Days 20052006 Separations/ Days 7,256 66,073 Separations Days ARHA Hospital 89.7% 92.5% OtherRHA Winnipeg 7.7% 5.2% 0.9% 0.7% Outof Province 1.7% 1.6% SOURCE:MCHPRHAINDICATORSATLAS2009 HospitalDaysUsed Assiniboine residents have a high rate of inpatient use with 1,356 days per 1,000 residents in 2005/2006, second only to Parkland RHA when the North of the province is excluded, and considerably higher than both the Manitoba average and the average for the Rural South. Table6.5HospitalDaysUsed2000/01and2005/06CrudeRates SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland RuralSouth Mid Manitoba HospitalDaysUsed NumberObserved NumberObserved CrudeRate/1,000 CrudeRate/1,000 PerYear PerYear 2000/2001 2005/2006 41,826 768.48 45,238 749.37 97,249 1004.28 97,810 966.86 117,033 1635.82 92,923 1356.24 62,831 1327.31 58,661 1191.69 592,478 912.89 545,857 823.91 62,165 829.49 60,626 789.24 37,509 952.75 36,730 917.97 64,335 1464.19 64,271 1523.30 256,108 1149.47 235,971 1025.76 164,009 1036.38 161,627 1016.39 1,194,160 1036.69 1,093,794 930.70 SOURCE:MCHPRHAINDICATORSATLAS2009 PG:158CHAPTER6:PREHOSPITALANDHOSPITALBASEDCARE This high rate of inpatient use is likely influenced by the high proportion of elderly residents in the region, but although the age and sex adjusted figures are less pronounced, they still show a relatively high inpatient use in the region. Figure6.7HospitalDaysUsedRates/1,0002000/01and2005/06(AgeandSex Adjusted) 2000/01 2005/06 MBAvg2000/01 MBAvg2005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland RuralSouth Mid Manitoba 0 200 400 600 800 1000 1200 1400 1600 SOURCE:MCHPRHAINDICATORSATLAS2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:159 When this hospitalization use is split into short stay (stays of less than 14 days) and long stays (stays of 14 or greater days), it is apparent that the most noticeable difference is in short stays with the region (456/1,000 in 2005-2006) being considerably higher than the Manitoba average (322/1,000 in 2005-2006) in both 2000-2001 and 2005-2006. Figure6.8HospitalDaysUsedforShortStays(<14Days)Rates/1,0002000/01and 2005/06(AgeandSexAdjusted) 2000/01 2005/06 MBAvg2000/01 MBAvg2005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0 100 200 300 400 500 600 700 800 900 1000 SOURCE:MCHPRHAINDICATORSATLAS2009 PG:160CHAPTER6:PREHOSPITALANDHOSPITALBASEDCARE Hospitalization use in long term stays in 2005-2006 (603/1,000) is comparable with the Manitoba average for the same time period (608/1,000). Figure 6.9 Hospital Days Used for Long Stays (>=14 Days) Rates/1,000 2000/01 and 2005/06(AgeandSexAdjusted) 2000/01 2005/06 MBAvg2000/01 MBAvg2005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland 2,939 Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0 200 400 600 800 1000 1200 1400 1600 SOURCE:MCHPRHAINDICATORSATLAS2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:161 AmbulatoryCareSensitiveConditions(ACS) Ambulatory Care Sensitive conditions are conditions that are generally considered preventable or manageable through ambulatory care. These types of admissions are assumed to reflect access to primary care. While not all admissions for ACS conditions may be avoidable, it is possible that ambulatory care may help to prevent onset, control acute episodes, or manage chronic conditions. These include conditions such as asthma, angina, and congestive heart failure. The rate of hospitalization for ACS conditions in the region has been particularly high in past years (19.2/1,000 in 2000/01) but has dropped dramatically in recent years (13.2/1,000 in 2005/06). It is still considerably higher than the Manitoba average (9.5/1,000 in 2005/06) but this is heavily influenced by the urban centres of Winnipeg and Brandon where rates are very low. Rates are particularly high in the North 1 and West 2 districts of the region. Figure6.10RateofHospitalizationforAmbulatoryCareSensitiveConditions2000/01 and2005/06per1,000ResidentsAged075(AgeandSexAdjusted) 2000/01 2005/06 MBAvg2000/01 MBAvg2005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0 5 10 15 20 25 30 SOURCE:MCHPRHAINDICATORSATLAS2009 35 PG:162CHAPTER6:PREHOSPITALANDHOSPITALBASEDCARE InjuryHospitalizationRates Injury hospitalization rates in the region, despite showing improvements in recent years, remain consistently higher than the Manitoba average. The rate per 1,000 residents has dropped from 11.9/1,000 in 1996/97-2000/01 to 9.9/1,000 in 2001/02-2005/06. This compares with Manitoba rates of 9.1/1,000 and 8.3/1,000 for the same time periods. Figure6.11RateofHospitalizationforInjuries2000/01and2005/06per1,000 Residents(AgeandSexAdjusted) 1996/972000/01 2001/022005/06 MBAvg1996/972000/01 MBAvg2001/022005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood South Mid North Manitoba 0 5 10 15 20 25 SOURCE:MCHPRHAINDICATORSATLAS2009 30 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:163 SurgicalProgram The region currently has three facilities offering varying degrees of general and minor surgical interventions: Minnedosa Health Centre has a General Practice Surgeon, performing general surgical procedures as well as itinerant ophthalmology (e.g., cataract removal and lens implant) and orthopedic surgery. Neepawa Health Centre has a General Practice Surgeon, performing general surgical procedures as well as itinerant endoscopy and ear, nose, and throat surgery. Souris Health Centre offers itinerant endoscopy procedures and other minor surgery such as hernia repairs, carpal tunnel, biopsies, excision of lesions, and vasectomies. Staff indicate that having the surgical program contributes to shorter wait times. They also feel that it is possible to enhance the use of the resources and equipment that we have through communication with physicians about the surgical services offered in the region. In 2008/2009, over 1,500 surgical intervention were carried out in the region’s facilities, either on a same day care or inpatient basis. Table6.6SurgicalInterventionsinARHAFacilities2007/20082008/2009 20072008 20082009 Inpatient SameDayCare Inpatient SameDayCare 178 345 233 330 Endoscopy 571 601 Ophthalmology 212 203 Orthopedics 205 188 GeneralSurgery SOURCE:ARHAMIS2009 Itisimportanttonotethatwhilstsomesurgicalproceduresarecarriedoutinregional facilities, the vast majority of procedures upon which the following indicators are based,arecarriedoutinfacilitiesoutsidetheregion,predominantlyinfacilitieseither inBrandonRHAorWinnipegRHA. PG:164CHAPTER6:PREHOSPITALANDHOSPITALBASEDCARE Tonsillectomy/Adenoidectomy Regional variations in tonsillectomy rates have been raised as a quality of care question in Manitoba and can suggest ‘clinical uncertainty’ around indications for this surgical procedure. This uncertainty can mean that patients may unnecessarily undergo a surgical procedure with all of its attendant risks and with little benefit. The regional rates for tonsillectomy procedures have been consistently higher than the Manitoba average, and along with Brandon, are the highest in the province. In the period 2001/02-2005/06 the region’s rate was 6.5/1,000 children aged 0-14 compared to a provincial average of just 4.7/1,000 and a Rural South average of 5.4/1,000. The North 2 district shows the highest rate at 7.7/1,000 and East 2 the lowest at 5.3/1,000. Figure6.12Tonsillectomy/AdenoidectomyRates/1,000Aged0141996/972000/01 and2001/022005/06(AgeandSexAdjusted) 1996/972000/01 2001/022005/06 MBAvg1996/972000/01 MBAvg2001/022005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood South Mid North Manitoba 0 1 2 3 4 5 6 7 8 SOURCE:MCHPCHILDHEALTHATLAS2008 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:165 CataractSurgery Cataract surgery is a procedure which involves the removal of the natural lens of the eye that has become opaque, causing impairment or loss of vision. During cataract surgery, a patient's cloudy natural lens is removed and replaced with a synthetic lens to restore the transparency of the lens. The region’s age and sex adjusted rate of cataract surgery is very similar to the Manitoba average at 28.0/1,000 residents aged fifty and over in 2005/06, compared to a rate of 28.4/1,000 in the province as a whole. There are generally slightly higher rates amongst females in the region. Due to the relatively high proportion of Assiniboine residents in the 50+ age group (compared to Manitoba as a whole), the crude values are somewhat higher with 805 cataract surgeries performed in 2005/06, a crude rate of 30.7/1,000. Hysterectomy A hysterectomy is the surgical removal of the uterus and sometimes the cervix. Removal of the body of the uterus without removing the cervix is referred to as a subtotal or partial hysterectomy and removal of the entire uterus and the cervix is referred to as a total hysterectomy. There is concern that hysterectomy is used too often as a first line treatment and is not necessarily always appropriate, particularly when performed for fibroids (benign tumour-like growths inside the uterus itself made up of muscle and connective tissue), where more conservative options in treatment are available. Hysterectomy rates in the region have shown a steady decline from 6.1/1,000 in 2002/03 to 4.9/1,000 in 2006/07 but have remained consistently higher than the Manitoba average during that time period, which is heavily influenced by the very low rate in Winnipeg. PG:166CHAPTER6:PREHOSPITALANDHOSPITALBASEDCARE Figure6.13HysterectomyRate2002/03–2006/07/1,000Aged25+(AgeAdjusted) 2002/032006/07 MBAvg2002/032006/07 S.Eastman 5.8 Central 4.6 Assiniboine 4.9 Brandon 4.8 Winnipeg 3.5 Interlake 4.2 N.Eastman 4.5 Parkland 4.6 NorMan 4.5 Burntwood 4.5 Manitoba 4.0 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 SOURCE:MANITOBAHEALTHINFORMATIONMANAGEMENT2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:167 ObstetricalServices Low risk obstetrical services are provided at one site in the region, the Neepawa Health Centre, offering epidurals as well as scheduled and emergency Caesarean sections. There are around 60 births on average at this facility every year. The majority of regional births take place in the Brandon RHA (78.4% in 2007/2008). Table6.7ARHAResidentBirthsbyRHA(DeliveryHospitalLocation)2004/2005 2007/2008 2007/2008 2006/2007 2005/2006 2004/2005 Assiniboine 70 79 95 107 Brandon 587 485 506 466 Winnipeg 31 29 34 40 Central 21 29 23 26 Parkland 7 11 6 10 Other 0 2 3 5 OutofProvince 33 33 29 30 SOURCE:MBHEALTHINFORMATIONMANAGEMENT2009 The proportion of Assiniboine residents giving birth in a facility within the region has dropped from 15.6% in 2004/2005 to just 9.3% in 2007/2008. Around 16% of deliveries at the Neepawa Health Centre in 2007/2008 were for residentsofotherRHAs,predominantlyCentralRHA. Some community members expressed concern that obstetrical services were no longer provided in most small hospitals. With low numbers of births in facilities, it is difficult to achieve the volumes necessary to maintain provider competency. Most acute sites in the region do not have access to Caesarean section capacity within a time frame considered reasonable for safe care. For these reasons, the risks of resuming obstetrical services in small facilities without surgical capacity outweigh the benefits. CaesareanSections The type of delivery can have an impact on the newborn’s health. Babies delivered via Caesarean section are at increased risk of a number of complications including respiratory problems and difficulties breastfeeding. There is also an increased risk of complications for the mother with this type of delivery. PG:168CHAPTER6:PREHOSPITALANDHOSPITALBASEDCARE The region has a very high Caesarean section rate, significantly higher than the Manitoba average in both 1996/97-2000/01 (19.3% compared to 17.4%) and 20001/02-2005/06 (23.6% compared to 19.5%) and has increased significantly (up 4.3%) in this time frame. District level rates in the region vary from, 20.6% in East 2 to 29.6% in North 2. Brandon RHA has similarly high rates indicating that whilst it is true that Caesarean sections are increasing provincially, the particularly high rates seem to be a localised issue. Figure6.14CaesareanSectionRate1996/972000/01and2001/022005/06(Age Adjusted) 1996/972000/01 2001/022005/06 MBAvg1996/972000/01 MBAvg2001/022005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood South Mid North Manitoba 0% 5% 10% 15% 20% 25% 30% SOURCE:MCHPCHILDHEALTHATLAS2008 VaginalBirthafterCaesareanSection The vaginal birth after caesarean section (VBAC) rate is an important indication of the effort to reduce unnecessary Caesarean sections when there is no indication for a Caesarean section and evidence that Caesarean sections may increase complications for both the mother and newborn. The region’s rate for this indicator is not significantly different (32.8% in 2001/02-2005/06) to the Manitoba average (34.7%). Amongst the lowest rates in the region can be found in the North 2 district which also showed the highest Caesarean section rates. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:169 RiversRehabilitationUnit The Rivers Rehabilitation Unit is an 11 bed facility staffed with physicians, rehabilitation aides, nurses, a rehabilitation activity worker, physiotherapist, and occupational therapist. It was initiated in 2005 to respond to a growing need for orthopedic rehabilitation services. The majority of patients admitted have recently had hip or knee surgery, however other patients requiring orthopedic rehabilitation have also received rehab services in Rivers. The program has accepted medical rehabilitation patients (e.g. stroke victims) when beds are available. From 2006/2007 to 2008/2009, 344 residents of the Assiniboine and Brandon RHAs have undergone rehabilitation at the unit. The Rivers Rehabilitation Unit has been providing a valuable service. Staff from other sites in the region indicate that rehabilitation in the acute centres could be improved. Table6.8RiversRehabilitationUnitStatistics2006/072008/09 20062007 20072008 20082009 52% 50% 75% Number 110 91 108 Avg.LOS(days) 22.0 21.1 25.8 4 16 15 15.3 23.2 46.9 UnitOccupancy Orthopedic RehabPatients MedicalRehab Patients Number Avg.LOS(days) SOURCE:DISCHARGEABSTRACTDATABASE2009 The majority of referrals to the unit have come from the Brandon Regional Health Centre, Boundary Trails, and Concordia, where orthopedic surgery is carried out. Over 75% of patients have been discharged home from the Rivers Rehabilitation Unit with home care services where applicable. HipandKneeReplacements Almost 80% of referrals to the Rivers Rehabilitation Unit have been patients who have recently undergone hip or knee surgery. Reducing wait times for hip and knee surgery has been a provincial priority in recent years. Along with the province as a whole, the rate of both hip and knee replacement procedures has shown a significant increase between 1996/97-2000/01 and 2001/02-2005/06. Hip replacements in the Assiniboine region are slightly above both the provincial and rural south averages in the second time period. Knee replacements, however, are slightly below the provincial and Rural South averages in the second time period. PG:170CHAPTER6:PREHOSPITALANDHOSPITALBASEDCARE Table6.9HipandKneeReplacementsRate/1,000Residentsaged40+1996/97 2000/01and2001/022005/06(AgeandSexAdjusted) TotalHipReplacement/1,000 TotalKneeReplacement/1,000 1996/97 2000/01 2001/02 2005/06 1996/97 2000/01 2001/02 2005/06 Assiniboine 1.70 2.25 1.80 2.64 RuralSouth 1.72 2.19 2.03 2.75 Manitoba 1.71 2.18 2.04 2.84 SOURCE:MCHPRHAINDICATORSATLAS2009 Physiotherapy/OccupationalTherapy According to the Canadian Physiotherapy Association, physiotherapy is dedicated to: Improving and maintaining physical mobility and independence, Preventing, managing and reducing pain, physical limitations, or disabilities that may limit the clients activities, and Improving overall fitness, health, and well-being. The Canadian Association of Occupational Therapy website reports that occupational therapy is the art and science of: Enabling engagement in everyday living, through occupation, Enabling people to perform the occupations that foster health and well-being; and Enabling a just and inclusive society so that all people may participate to their potential in the daily occupations of life. Prior to January 2010, physiotherapy and occupational therapy services were contracted for the Assiniboine Region through Community Therapy Services. As of January 2010, the physiotherapists and occupational therapists became employees of the Assiniboine region. Therapy services may offer services to hospital patients, outpatients, personal care home residents, and home care clients. Community members and staff recognize the value of physiotherapists and occupational therapists. Staff have said that we do not currently have enough therapy resources to meet the demand. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:171 RenalCare/Dialysis Many Canadians suffer from kidney disease. People with diabetes, high blood pressure, cardiovascular disease, and other conditions, may be at risk of kidney disease. For some, their kidneys no longer work properly, leading to the need for dialysis. Early identification of kidney disease and referral can improve outcomes. According to the Manitoba Renal program, Manitoba has the highest rate of kidney disease in Canada and the number of Manitobans requiring dialysis has doubled in the last decade. When the kidneys are no longer functioning properly, a decision must be made about treatment. Treatment for kidney failure can include hemodialysis, peritoneal dialysis, transplant, or no treatment. Currently, dialysis is provided through the Manitoba Renal program, with renal services available at three Winnipeg hospitals, Brandon Regional Health Centre, and 13 satellite local centres in rural and northern Manitoba and NW Ontario. The Manitoba Local Centres Dialysis Units (MLDCU) is an innovative program for delivering specialized renal care to local communities in rural and northern Manitoba as well as north-western Ontario. Providing dialysis in these communities has enhanced the quality of life of many patients by allowing dialysis closer to home. Because dialysis is usually needed three times a week, this program may help clients access services without having to relocate. Local Centres close to the Assiniboine region are located in Brandon, Dauphin, and Portage. Many Assiniboine residents access dialysis through the Local Centre in Brandon, which is striving to keep up with demand. Over the past year, there have been more than 30 Assiniboine residents who access the Brandon Dialysis Unit every month. In order to meet the growing need for dialysis, the Assiniboine region is establishing a dialysis unit in Russell. At the time of writing, construction was scheduled to begin in the spring of 2010, with an anticipated opening date for this unit in the spring of 2011. Assiniboine residents asked about the dialysis unit frequently during the community engagement meetings and anxiously await the opening of this new Local Centre. PG:172CHAPTER6:PREHOSPITALANDHOSPITALBASEDCARE SpiritualHealth The purpose of the Assiniboine Regional Health Authority Spiritual Health program is to help both individuals and communities to experience healing in the many dimensions of their lives. Providers of Spiritual Health collaborate with others to improve the community’s health. The key functions of the Spiritual Health program are: Spiritual & religious visitation Spiritual counselling Worship services Religious rites Memorial services Crisis involvement The primary objectives of the Spiritual Health program’s health and healing ministry are: To be available and accessible to individuals and/or their family and care providers across the continuum of care, especially those experiencing spiritual distress; To assess the spiritual and religious needs of the care recipient across the continuum of care; To develop and implement a spiritual health plan to meet the individual’s needs; To empower individuals to understand the inter-relationship between their spiritual, religious, physical, psychosocial, emotional, and cultural aspects; To provide appropriate opportunities for worship, prayer, sacraments, and other rituals; To facilitate experiences of supportive community; and To encourage follow-up that meets ongoing spiritual and religious needs. There are strong connections between the Spiritual Health and Palliative Care programs. Linkages also exist with the regional Trauma Team and the Brandon RHA Spiritual Health program. Some Assiniboine residents who may experience difficulty meeting their spiritual health needs while under our care, are clients whose faiths aren’t represented by the spiritual organizations within the community (e.g., immigrants, First Nations, Muslims). With increasing diversity in our communities, this gap may become more evident. There are efforts underway to meet the spiritual needs of clients as much as possible. Some facilities may not allow traditional practices, but the region is exploring ways to enhance cultural sensitivity to accommodate the needs of clients. Dietitians can assist with adapting menus to meet special dietary needs, such as kosher foods. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:173 Staff and partners involved with the Spiritual Health program would like to increase awareness of the program among all staff. Regional staff play an important role in assessing clients’ spiritual health needs and making the appropriate referrals. When acute care clients were asked in Client Satisfaction Questionnaires about the quality of Spiritual and Pastoral Care services provided: 68% reported having no contact or did not answer 20% rated the quality of Spiritual & Pastoral Care as excellent 11% reported that the quality of Spiritual & Pastoral Care was either good or fair Long term care residents and families were asked about their opportunity to participate in religious programs through the Client Satisfaction Questionnaire. Results from the various personal care homes were as follows: In 5 Personal care homes 100% of residents/families said they had an opportunity to participate in religious programs In 7 Personal care homes between 90 and 99% of residents/families said they had an opportunity to participate in religious programs In 10 Personal care homes between 80 and 89% of residents/families said they had an opportunity to participate in religious programs In 4 Personal care homes between 70 and 79% of residents/families said they had an opportunity to participate in religious programs QualityofCare HealthcareAssociatedInfections Healthcare associated infections are of concern in the acute care setting where sick and often frail clients are in close proximity and more susceptible to infections. Particular care is given to restrict the spread of infection with regular hand washing and the use of alcohol rubs by staff working in the facilities. A comprehensive reporting system is used to track infections in order to quickly identify and address any outbreaks. In the fiscal year 2008/2009, 187 healthcare associated infections were reported in the region’s acute and transitional care centres, the majority of which (52%) were urinary tract infections. This represents a modest increase from the 2007/2008 value of 171. PG:174CHAPTER6:PREHOSPITALANDHOSPITALBASEDCARE AcuteCareFacilityFalls According to the Canadian Safer Healthcare Now! initiative, falls and injury from falls are critical issues in health care safety. The number of falls reported in the region’s acute care centres steadily increased from 273 for the six month period January-June 2006 to 368 in the six month period July-December 2008, an increase of 35%. The first half of 2009 has shown a decline in this number to 327. The region is developing a comprehensive falls prevention, assessment, and management program in an attempt to address this issue. Figure6.15AcuteCareFacilityFallsJanJun2006JanJun2009 AcuteCareFacilitiesFalls 400 373 350 370 368 337 300 250 327 311 273 200 150 100 50 0 01062006 07122006 01062007 07122007 01062008 07122008 01062009 SOURCE:ARHAINCIDENTREPORTS2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:175 MedicationVarianceIncidents A medication variance incident occurs when an inpatient does not receive the correct amount or type of medication within the time frame specified for that medication. The rate of medication variance incidents has steadily increased from 4.2/1,000 inpatient days in 2005/2006 to 5.0 in 2008/2009, an increase of 19% in the four year period. The period 2008/2009 has shown a modest improvement, down 6% from the previous year, likely due to the implementation of the Medical Reconciliation at Admission process, which is designed to prevent medication errors at patient transition points. The most common medication variances reported in acute care facilities are omitted dose, incorrect dose, and incorrect time. Figure6.16AcuteCareFacilities–MedicationIncidentsper1,000InpatientDays 2004/20052008/2009 AcuteCareFacilitiesMedicationIncidents 6.0 5.3 5.0 5.0 4.5 4.0 4.2 3.0 2.0 1.0 0.0 2005/2006 2006/2007 2007/2008 2008/2009 SOURCE:ARHAINCIDENTREPORTING2009 PG:176CHAPTER6:PREHOSPITALANDHOSPITALBASEDCARE ChapterHighlights Call volumes in EMS have been steadily increasing. Staffing shortages are challenging the program’s ability to maintain operations in all stations. Maintaining access to acute and emergency care was the most frequently reported concern of the community. A number of facilities are offering transitional care, which reduces demand on acute care beds. The majority of infants born to Assiniboine women are delivered in hospitals outside the region. The Rivers Rehabilitation Unit is providing a valuable service for orthopedic surgery clients; however, there is a lack of resources for medical rehabilitation. There is a growing demand for renal replacement therapy in the province; a hemodialysis unit is planned for Russell. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:177 Chapter7:PublicHealth The Assiniboine Public Health program works with residents and their families to ensure that they have the information, skills, and support to make decisions about personal and family health. Public health nurses work to strengthen communities by providing health care and the information and resources necessary to maintain and strengthen health. They promote networks, partnerships, and the use of community resources and programs. Community members value the Public Health program. During the community engagement meetings, people discussed the importance of maintaining adequate staffing and listed Public Health programs as important services that promote health. Public Health staff felt that there may be a lack of public awareness of the role and skills of public health nurses. It was felt that this could be improved through promotion of the program to the public and to new physicians. Areas for improvement identified by staff included an improved charting system, better access to technology, and defined role of administrative support. It was felt that these improvements could allow public health nurses to spend more time with clients. PregnancyandChildBirth In the Assiniboine region, there are many supports for expectant mothers and families with infants and young children. A pregnant mother’s choices, the prenatal experience, and prenatal care can have lasting effects on her child. Staff indicate that it is important for expectant mothers to seek prenatal care early in their pregnancy. Delays in accessing prenatal care can lead to pregnancy complications and poor birth outcomes for infants. Anecdotal evidence indicates that women in minority groups may be less likely to access early prenatal care for a number of reasons. Staff have said that some women may delay accessing prenatal care because of distance. It was suggested that it may be valuable to provide information about prenatal education options during the orientation of new physicians. PrenatalEducation Prenatal education is offered across the region by local public health nurses in one day sessions held on a Saturday. Session content includes information on labour & birth, breastfeeding/infant feeding, postnatal maternal and newborn care, and family adjustment. In 2009, there were 14 prenatal classes held across the region with 101 expectant mothers and their partners attending, the vast majority of whom were first time mothers. In addition, Baby Steps, which is a community supported program for expectant mothers and mothers with babies up to one year of age, to come together with other parents to share and learn in a friendly casual setting. Sessions occur once or twice monthly and PG:178CHAPTER7:PUBLICHEALTH focus on topics such as pre/postnatal health, nutrition, early child development, and parenting. Healthy Baby also offers a prenatal benefit program for families with an income less than $32,000/year. Pregnancy Pregnancy rates in the region are generally slightly lower at 53.5/1,000 residents (2004/05-2006/07) than the rate for Manitoba as a whole (59.6/1,000). By far the highest rate is in the age group 25-29 at 162.0/1,000. Table7.1PregnancyRate/1,000byAgeGrouping2004/052006/07 1014 1519 2024 2529 3034 3539 Assiniboine 0.4 24.6 93.4 162.0 110.0 39.5 6.0 0.4 53.5 Manitoba 0.9 45.3 102.1 129.7 108.0 46.0 8.5 0.4 59.6 4044 4549 Total SOURCE:MANITOBAHEALTHINFORMATIONMANAGEMENT2008 In common with all pregnancies in the region, the most popular age for the first pregnancy is in the age group 22-29. This is relatively high compared to Manitoba as a whole where the highest rate for first pregnancy appears in the 18-21 age group. Table7.2AgesatFirstPregnancyRate/1,000byAgeGrouping2001/022003/04 Less than18 1821 2229 3039 4049 Assiniboine 13.6 33.6 41.4 8.9 0.3 Manitoba 25.0 47.2 36.2 12.7 0.5 SOURCE:PRAIRIEWOMEN’SHEALTHREPORT2008 Teenpregnancy Teen pregnancy rates in the region were calculated for two time periods; 1996/972000/01 and 2001/02-2005/06. In both cases, the region’s rates (34.3/1,000 and 27.9/1,000) were significantly lower than the Manitoba average (62.7/1,000 and 49.8/1,000) and the national average (45.6/1,000 and 36.1/1,000), suggesting a very effective Reproductive Health program. The region’s Reproductive Health program includes education and counselling, both oneon-one and in small groups, targeted towards reproductive choices and harm reduction. The program also offers assistance with birth control supplies for persons in financial need. Staff mentioned that it can be difficult for clients to access physician appointments ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:179 in a timely manner for prescriptions and required cervical screening. It was suggested that this could be a role for primary care nurses, who are trained to do the screening and could offer a wider variety of options. Public health staff also felt that having more time to go to the schools would increase accessibility for youth. Students wished to have better access to realistic information and to be able to have their questions answered without feeling that they were being judged. In the region in the 2008/2009 fiscal year there were 1,236 visits to a public health nurse office regarding reproductive health issues and an additional 131 school visits. Figure7.1TeenPregnancyinWomenAged1519(cruderateper1,000) 1996/972000/01 2001/022005/06 MBAvg1996/972000/01 MBAvg2001/022005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood South Mid North Manitoba 0 25 50 75 100 125 150 175 SOURCE:MCHPCHILDHEALTHATLAS2008 PG:180CHAPTER7:PUBLICHEALTH BirthRate Despite the declining population in the region over the last few years the number of births has remained relatively stable at an average of 680 per year. This has meant that the birth rate in females between 15 and 49 has slowly increased from 44.9/1,000 (699 births) in 2000/01 to 46.2/1,000 (668 births) in 2006/07. Figure7.2RegionalBirthrateper1,000FemalesAged1549,2000/012006/07 48 47.6 47 46.2 46 46.0 45 44.9 44.9 44.3 44 44.1 43 2000/2001 2001/2002 2002/2003 2003/2004 2004/2005 2005/2006 2006/2007 SOURCE:MBHEALTHINFORMATIONMANAGEMENT ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:181 BirthWeight Birth weight of infants can influence birth outcomes and long term health status. High birth weight in infants can increase the risk of complications during and after delivery for both mother and infant. Low birth weight infants are also at higher risk of complications and potential health problems throughout their lives. Early access to prenatal care may help to improve birth outcomes. Table7.3LowBirthWeight(<2500gms)20022007 2002/2003 2003/2004 2004/2005 2005/2006 2006/2007 2002/03 2006/07 Assiniboine 4.8% 2.8% 3.9% 4.2% 4.7% 4.1% Manitoba 5.0% 5.4% 5.5% 5.3% 5.5% 5.3% SOURCE:DISCHARGEABSTRACTDATABASE Table7.4HighBirthWeight(>4500gms)20022007 2002/2003 2003/2004 2004/2005 2005/2006 2006/2007 2002/03 2006/07 Assiniboine 17.1% 18.9% 16.5% 15.6% 15.8% 16.8% Manitoba 16.8% 17.1% 16.7% 15.8% 16.1% 16.5% SOURCE:DISCHARGEABSTRACTDATABASE The percentage of low-weight births in the region is marginally lower than that in Manitoba as a whole, whilst the percentage of high-weight births is almost identical to the Manitoba rate. PG:182CHAPTER7:PUBLICHEALTH SizeforGestationalAge A potentially more informative measure of birth weight or fetal growth is the ‘size for gestational age’ indicator which takes into account whether the birth was preterm, term, or post-term. Small for gestational age is considered an indicator of fetal growth restriction and a marker for increased fetal and infant mortality and morbidity risk. Large for gestational age is considered an indicator of accelerated fetal growth and a marker for increased risk of birth complications and infant morbidity. In both the ‘small for gestational age’ and ‘large for gestational age’ measures, the region’s rate is not significantly different than that of Manitoba as a whole during the two reported time periods of 1996/97-2000/01 and 2001/02-2005/06. Table7.5SizeforGestationalAge(SexAdjusted)1996/972005/06 SmallforGestationalAge LargeforGestationalAge 1996/972000/01 2001/022005/06 Assiniboine Manitoba Assiniboine Manitoba 7.5% 8.4% 6.5% 7.5% 13.4% 13.4% 14.7% 14.6% SOURCE:MCHPCHILDHEALTHATLAS2008 To provide an indication of the size of these babies, the average birth weight for Manitoba newborns in 2001/022005/05 was 3,466gms or 7.6 pounds. The average birth weight for those considered large for gestational age was 4,236gms or 9.3 pounds and theaveragebirthweightforthoseconsideredsmallforgestationalagewas2,617gmsor 5.8pounds. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:183 PretermBirths A preterm birth is a birth which occurs prior to 37 weeks gestation and is the most important determinant of fetal and infant mortality. The preterm birth rate in the region is not significantly different from that in Manitoba as a whole. Figure7.3PercentofPretermBirths(SexAdjusted),1996/97–2005/06(Pretermis lessthan37weeksgestation) 1996/972000/01 2001/022005/06 MBAvg1996/972000/01 MBAvg2001/022005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland South Mid Manitoba 0% 2% 4% 6% 8% 10% SOURCE:MCHPCHILDHEALTHATLAS2008 PG:184CHAPTER7:PUBLICHEALTH TeenBirthRates Research suggests that teen mothers have reduced educational and employment opportunities. These outcomes have an influence on the children of teen mothers, who have been found to be at greater risk of poor health and educational outcomes compared to those of mothers who delayed childbirth. The teen birth rate in the region for the two time periods studied (21.1/1,000 in 1996/97-2000/01 and 17.7/1,000 in 2001/02-2005/06) is significantly lower than the Manitoba average in the same periods (36.2/1,000 and 30.1/1,000) . Figure7.4TeenBirthRateofWomenAged1519(Ageadjustedrateper1,000) 1996/972000/01 2001/022005/06 MBAvg1996/972000/01 MBAvg2001/022005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood South Mid North Manitoba 0 25 50 75 100 SOURCE:MCHPCHILDHEALTHATLAS2008 125 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:185 PostpartumProgram The ARHA Postpartum program provides support and information for new mothers and families on postnatal maternal and infant care, breastfeeding, infant feeding, attachment, parenting of newborn, and family adjustment. Services are provided through phone contact and home visits. Staff suggested that there is room for improvement in response times for postpartum referrals. The Brandon RHA model of postpartum care was mentioned as noteworthy, with service available seven days a week for follow-up, which is not currently available in the Assiniboine RHA. In the fiscal year 2008/2009, there were 1,711 home visits made by public health nurses in the region as part of the postpartum program. A further 791 office visits and 2,038 phone contacts were also made in support of newborns and their families as part of this program. WellBaby/ChildHealthClinics Child Health or Well Baby Clinics are offered by public health nurses in the region to provide education and counselling regarding child care, nutrition, safety, breastfeeding, parenting, and community resources. Immunization is also offered at these clinics according to the provincial childhood immunization schedule. In the 2008/2009 fiscal year, 4,958 office visits were made to public health nurses as part of this program making a significant contribution to the well being of children and mothers in the region. Breastfeeding The multitude of health related, social, and economic benefits of breastfeeding (to both the mother and infant) in both the immediate and long term are well documented. Despite this, mothers continue either not to initiate breastfeeding or to discontinue nursing too soon, most often because of barriers at home, in the workplace, and even from healthcare providers in the form of early discharge from hospital. Breastfeeding initiation (measured as the percentage of mothers breastfeeding on discharge from hospital) in the region is almost identical to the Manitoba average at 83.3% in 2001/02-2005/06 compared to 81.6% in the province as a whole. This has increased marginally from the 1996/97-2000/01 value of 82.0% but is noticeably lower than the rate for the Rural South of 86.6%. In fact, the Assiniboine region is the only RHA in the Rural South not to have shown a significant increase between the two time periods. PG:186CHAPTER7:PUBLICHEALTH Stillbirths A stillbirth refers to the death of a baby before delivery. The stillbirth rate, or fetal mortality rate for the region, was calculated by taking the number of stillbirths per 1,000 total births. The region’s rate is not significantly different to that of Manitoba, and whilst the rate appears to have increased over the two time periods, the change is not statistically significant. Although there is no association between income and stillbirths, the mother’s age does appear to be a factor, with the rate for mothers over the age of 35 (11.5/1,000) being more than double that of younger mothers (5.5/1,000 for mothers aged 30-34). Figure7.5StillbirthRateper1,000,19962000and20012005 1996/972000/01 2001/022005/06 MBAvg1996/972000/01 MBAvg2001/022005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood South Mid North Manitoba 0 2 4 6 8 10 SOURCE:MCHPCHILDHEALTHATLAS2008 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:187 InfantMortality Infant mortality is considered a useful indicator of the level of health within a population. Figure 1.2 shows infant mortality for two five–year time periods: calendar years 1996– 2000 and 2001–2005. The rate of infant mortality in the region is not significantly different to that in Manitoba as a whole, nor has it changed markedly between the two time periods. Figure7.6InfantMortalityRate(Underoneyear)–CrudeRateper1,000births1996 2000and20012005 Born19962000 Born20012005 MBAvg19962000 MBAvg20012005 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood South Mid North Manitoba 0 3 6 9 12 SOURCE:MCHPCHILDHEALTHATLAS2008 The data excludes stillbirths and infants less than 500 gms or 22 weeks of gestation commonly referred to as ‘fragile infants’. Infant mortality is strongly related to socioeconomic status, particularly in rural areas, and the mortality rate for the lowest income areas is more than twice that of the highest income area. The most common causes of infant mortality are congenital abnormalities accounting for 30% of the deaths in all children under the age of one between 2001 and 2005. For neonates, this figure is even higher at 35% with complications of labour (12%) and short PG:188CHAPTER7:PUBLICHEALTH gestation/low birth weight (14%) also being significant. In post-neonates, sudden infant death syndrome (SIDS) (15%) and respiratory system problems (11%), as well as congenital abnormalities (21%), are more prevalent. ChildHealth There is growing evidence of the importance of early childhood development as a determinant of health. Early experiences and relationships, particularly during the first six years of life, have a lasting impact on learning, behaviour, and health. ChildMortality Child mortality for the region is expressed as the rate of death amongst those children aged 1-19 per 100,000. In common with infant mortality, the Assiniboine region’s rate is not significantly different from that of Manitoba as a whole. Figure7.7ChildMortality(Aged019)per100,00019962000and20012005 19962000 20012005 MBAvg19962000 MBAvg20012005 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland South Mid Manitoba 0 10 20 30 40 50 60 70 80 SOURCE:MCHPCHILDHEALTHATLAS2008 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:189 There is a significant relationship between child mortality and area-level income in rural areas with the lowest income areas having a rate two and a half times that of the highest income area. InjuryMortality By far the greatest cause of child mortality is injury (including self-inflicted) which accounts for around 60% of all deaths, ranging from almost half of deaths in children one to fourteen, to almost three quarters of deaths in youths aged fifteen to nineteen. The relationship between child injury mortality and area level income is even more significant than that of child mortality as a whole, with the rate in the lowest income areas being more than four times that of the highest income areas. Males tend to have higher injury mortality rates, particularly in adolescence, where the rates are two and half times that of females of the same age group. Motor vehicle and self-inflicted injuries were the most common causes of death for children up to age 19. Figure7.8CausesofInjuryMortalityinChildrenuptoAge19,20012005(Manitoba) OTHER 15% DROWNING 8% SUFFOCATIONAND CHOKING 13% VIOLENCEBY OTHERS 12% MOTORVEHICLE 25% SELFINFLICTED 27% SOURCE:MCHPCHILDHEALTHATLAS2008 PG:190CHAPTER7:PUBLICHEALTH FamiliesFirstProgram Assessing health risk is one of the central tasks of Public Health. The early years comprise a significant period of brain development and set the foundation for health and success in all aspects of life. The family environment is very influential in child development, making it essential to identify which situations, stressors, or behaviours are known to be associated with family difficulties. These situations, stressors or behaviours are called risk factors. In partnership with Healthy Child Manitoba, the Assiniboine Regional Health Authority attempts to screen all families with newborns for risk factors associated with poor child outcomes, using the Families First Screening Form. This screening form is a brief measure of biological, social, and demographic risk factors. Included on the form are congenital anomalies, birth weight, multiple births, alcohol use and smoking during pregnancy, mother’s age, education, marital status, mental health, and family social isolation and relationship distress. The screening process does not include families from First Nations reserves because of provincial/federal jurisdictions. Public health nurses gather the information from the post-partum referrals and through open-ended interviews usually within the week following the birth. The purpose of the universal screening process is two-fold. First, the screening process is used to direct families to appropriate resources such as child care, parenting programs, financial assistance, or home visiting programs. Secondly, the information is used for tracking risk factors for planning services and for policy development. When three or more risk factors are identified through a Families First Screen, a more detailed parental survey is undertaken to determine whether the family is offered enrolment into the Families First Home Visitor program. Over 80% of those offered the program in 2005 and 2006 accepted the service. This program offers the family weekly visits in the family's home for approximately one year, and then depending on the needs of the family, will gradually decrease in frequency. The program is designed to provide long term support lasting for about 3 years. Home Visitors work directly with the families using a parenting curriculum and work under the direction of a supervisor and the family's public health nurse. The curriculum supports families in the following areas: Healthy childhood growth, development, and learning Building strong family relationships and parenting skills Sharing information about child development Providing information on health, safety, and nutrition Learning through play Exploring solutions to challenging situations Providing information about pregnancy and spacing of children Accessing health and social services Connecting to community resources ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:191 The region’s Public Health program has been particularly successful in ensuring that every family with a newborn is screened with an average of over 98% of families screened between 2003 and 2006. Figure7.9Percentoffamilieswithnewbornsscreened20032006 AssiniboineRHA Manitoba 100% 99.4% 99% 98.8% 98.5% 98% 97.3% 97% 97.3% 96% 95.6% 95% 94.7% 94% 93.9% 93% 92% 91% 2003 2004 2005 2006 SOURCE:HEALTHYCHILDMANITOBA2009 Of the families that were screened during this time period (2003-2006), the proportion that were assessed to have three or more risk factors (21.1%) was significantly lower than that of Manitoba as a whole (24.4%) and has remained relatively stable throughout. Table7.6PercentofFamiliesScreenedwith3ormoreRiskFactors20032006 2003 2004 2005 2006 Assiniboine 19.8% 21.0% 21.1% 22.2% Manitoba 23.3% 24.1% 24.8% 25.0% SOURCE:HEALTHYCHILDMANITOBA2009 PG:192CHAPTER7:PUBLICHEALTH A district level analysis of families screening with three or more risk factors shows consistent and significantly lower rates in both the West 1 and East 2 districts of 14.6% and 15.8% respectively, compared to the regional average of 21.1%. The other districts are not significantly different from the regional average and no district has shown a significant increase or decrease between 2003 and 2006. Figure7.10PercentofFamiliesScreenedwith3ormoreRiskFactors20032006by DistrictofResidence District ManitobaAvg. 22.2% WEST2 14.6% WEST1 15.8% EAST2 19.3% EAST1 23.8% NORTH2 23.1% NORTH1 0% 5% 10% 15% 20% 25% 30% SOURCE:HEALTHYCHILDMANITOBA2009 FamiliesFirstRiskFactors The Families First Screening Form gathers information on 39 different risk factors, a summary of which is shown in the following table. The table details each risk factor (some have been combined) and its prevalence (the percentage of families at risk) for both the region and Manitoba as a whole. Following these are indications of whether the region’s rate is significantly higher or lower than that of Manitoba and for each district; whether that district’s rate is significantly higher or lower than that of the region. These are indicated by either (H), indicating the rate is significantly higher or (L), indicating that the rate is significantly lower. The absence of either indicates that the rate is not significantly different. Following the table is a list of the risk factors and a description of how each was assessed. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:193 Table7.7FamiliesFirstRiskFactors20032006 DisabilityorCongenitalAnomaly Assiniboine Manitoba N1 N2 E1 E2 W1 W2 2.2% 1.6% H LowBirthWeight 3.3% 5.4% L HighBirthWeight 14.4% 14.6% D PrematureBirth 5.6% 7.7% L InfectionsTransmittedinUtero 0.4% 0.7% AlcoholUseDuringPregnancy 20.9% 12.9% H (H) (H) D (L) D (L) DrugUseDuringPregnancy 1.8% 4.2% L DifficultLabour 14.6% 12.4% H InfantTraumaorIllness 2.8% 3.4% FamilyHistoryofDisability 6.2% 2.5% H MultipleBirths 2.6% 2.9% SmokingDuringPregnancy 18.0% 21.0% L (L) TeenageMother 1.0% 2.5% L Motherwith<HighSchool 22.3% 21.6% (L) (H) (H) (L) (L) FinancialSupportorDifficulties 9.2% 17.7% L (L) SingleParentFamily 5.8% 12.8% L LackofPrenatalCare 1.3% 2.9% L MaternalDepression/Anxiety 14.1% 14.1% (L) (H) Schizophrenia/BPD(Mother) 0.3% 0.4% MentallyDisabled(Mother) 0.2% 0.4% AntisocialBehaviour(Mother) 0.2% 0.4% MaternalSubstanceAbuse 0.3% 0.9% L ProlongedMaternalSeparation 0.9% 1.3% L LackofBonding 0.3% 0.3% FamilySocialIsolation 4.8% 5.2% I (L) RelationshipDistress/Violence 4.9% 6.0% L (H) InappropriateDiscipline 0.7% 0.6% ChildProtectionFile 3.1% 4.9% L MaternalChildhoodAbuse 5.3% 6.5% L PaternalChildAbuseHistory 3.5% 3.7% ParentalCriminalActivity 4.9% 4.5% SOURCE:HEALTHYCHILDMANITOBA2009 H L (H) (L) D I RegionalrateissignificantlyhigherthanManitobarate RegionalrateissignificantlylowerthanManitobarate DistrictrateissignificantlyhigherthanRegionalrate DistrictrateissignificantlylowerthanRegionalrate Rateisdecliningsignificantlyovertime Rateisincreasingsignificantlyovertime. PG:194CHAPTER7:PUBLICHEALTH Disability or Congenital Anomaly This risk factor includes major or moderate anomalies. Major anomalies include probability of permanent disability such as Down’s syndrome, cerebral palsy, or FASD (fetal alcohol spectrum disorder). Moderate anomalies include those for which a correction may be possible such as cleft palate or loss of limb. The prevalence of this risk factor in the region is significantly higher than that in Manitoba as a whole. Low Birth Rate This risk factor relates to infants who weighed less than 2,500 grams at birth and is significantly lower than Manitoba as a whole. High Birth Weight This risk factor relates to infants who weighed more than 4,500 grams at birth and is not significantly different to the Manitoba rate. Premature Birth This risk factor relates to infants who were born at less than 37 weeks gestation and is significantly lower than the Manitoba rate. Infections Transmitted in Utero This risk factor includes in utero infections that may endanger the developing fetus, such as rubella, AIDS, toxoplasmosis, and cytomegalovirus. Not included are Hepatitis B, if infant received prophylaxis: herpes, unless acquired. The prevalence of this risk factor is not significantly different to that of Manitoba as a whole. Alcohol Use by Mother during Pregnancy This risk factor is assessed by public health nurses who are instructed to ask every mother about her alcohol use during pregnancy. The rate of alcohol consumption during pregnancy for our region is significantly higher at 20.9% to Manitoba as a whole at 12.9%, and is a cause for concern given the possible connection to the higher rate of congenital anomalies in the region including FASD (Fetal Alcohol Spectrum Disorder). Alcohol use during pregnancy is particularly prevalent in the North 1 and North 2 districts. Drug Use during Pregnancy This risk factor is assessed by public health nurses who are instructed to ask every mother about their drug use during pregnancy. Not included in this risk factor is the use of nonteratogenic prescription drugs (teratogenic refers to the ability to disturb the growth and development of a fetus), small amounts of over the counter drugs, and cigarette smoking (assessed in a separate risk factor). The rate of drug use amongst pregnant women in the region is significantly lower than that of Manitoba as a whole. Difficult Labour This risk factor includes vaginal or Caesarian birth following long, difficult, and exhausting labor. This risk factor may include emergency situations or perineal trauma. The prevalence of this risk factor is significantly higher than that of Manitoba as a whole. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:195 Infant Trauma or Illness This risk factor includes infant trauma or illness surrounding the birth such as convulsions or respiratory distress syndrome. This applies to infants in the first 28 days of life, or until discharge, where an infant has been continuously hospitalized beyond the neonatal period. The prevalence of this risk factor is not significantly different to that of Manitoba as a whole. Family History of Disability This risk factor includes a family history of a disability not detectable at birth that could affect development such as deafness or mentally disabled or challenged. This usually includes parents, siblings, and aunts and uncles. Some public health nurses may also have included cousins and grandparents. The prevalence of this risk factor is significantly higher (more than twice) than that of Manitoba as a whole. Multiple Births This risk factor applies to multiple births (i.e. twins or triplets) and is not significantly different to Manitoba as a whole. Maternal Smoking during Pregnancy This risk factor is assessed by public health nurses who are instructed to ask every mother about cigarette smoking during pregnancy. The region’s rate (18%) is significantly lower than the rate for Manitoba as a whole (21%). Teenage Mother This risk factor includes all births where the age of the mother was less than 18 years old at the birth of the child. The region’s rate of teenage pregnancy is significantly lower than that of Manitoba as a whole. Mother with Less than High School Education This risk factor includes mothers with less than high school education, and includes mothers who are currently working on their Grade 12 or equivalency. The rate of this risk factor (although appearing quite high at 22.3%) is not significantly different to that of Manitoba as a whole. There are significantly higher rates of this risk factor in the East 1 and East 2 districts of the region. Financial Support or Difficulties This risk factor includes mothers who are either on social assistance or income support, or who report financial difficulties. Financial difficulties are defined as having insufficient monies available to meet basic needs after meeting financial commitments. The prevalence of this risk factor is significantly lower than Manitoba as a whole at almost half. PG:196CHAPTER7:PUBLICHEALTH Single Parent Family This risk factor includes mothers who identify as the sole primary care giver for their child. This may include the following categories: unmarried, separated, widowed, divorced, or common-law relationship of less than one year. The prevalence of single parent families in the region is less than half that of Manitoba as a whole. Lack of Prenatal Care This risk factor applies to a lack of prenatal care before the sixth month of pregnancy and its prevalence in the region is significantly lower than that in Manitoba as a whole. Maternal Depression and/or Anxiety Maternal Schizophrenia or Bipolar Disorder These risk factors are assessed by the public health nurse who has knowledge of a mother’s professional diagnosis. This is sometimes determined by noting medication use. The prevalence in the region of these risk factors is not significantly different to that in Manitoba as a whole. There is a higher rate of maternal depression and/or anxiety in the West 2 district of the region. Maternal Mental Disability This risk factor applies to a mother’s mental disability, which may make learning new information difficult. The prevalence in the region of this risk factor is not significantly different to that in Manitoba as a whole. Maternal Antisocial Behaviour This risk factor includes antisocial behaviour such as unlawful behaviour, repeated lying, poor work history, repeated assaults, reckless with safety, not honoring financial obligations, cannot sustain monogamous relationship for a year, or history of failure to care for a child. The prevalence in the region of this risk factor is not significantly different to that in Manitoba as a whole. Maternal Substance Abuse This risk factor is assessed by public health nurses who are instructed to ask every mother about their substance use during pregnancy. The prevalence of substance abuse in the region amongst mothers is significantly lower than that of Manitoba as a whole. Prolonged Postpartum Separation This risk factor refers to mothers who have had little or no contact with her infant for 5 or more days. The prevalence of this risk factor is significantly lower in our region than that in Manitoba as a whole. Lack of Bonding This risk factor is assessed by public health nurses who observe signs of lack of bonding between mother and her infant. These may include minimal eye contact or touching. The prevalence in the region of this risk factor is not significantly different to that in Manitoba as a whole. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:197 Family Social Isolation This risk factor refers to mothers who indicate no social support. The isolation can also be due to culture, language, or geography. The prevalence in the region of this risk factor is not significantly different to that in Manitoba as a whole but is increasing over time. Relationship Distress / Violence This risk factor refers to distress or conflict between parenting partners, such as separations and frequent arguments. Violence refers to a current or history of violence between parenting partners. Public health nurses are instructed not to ask about partner violence when both partners are present. The prevalence of this risk factor is significantly lower in the region than that in Manitoba as a whole. There is a higher rate of this risk factor in the West 2 district of the region corresponding with the high rate of maternal depression and/or anxiety. Inappropriate Discipline This risk factor refers to the harsh and/or inappropriate discipline practices by the parent(s), as self-reported. This may include the harsh and/or inappropriate discipline practices the mother or father has used with their other children. The prevalence in the region of this risk factor is not significantly different to that in Manitoba as a whole. Child Protection File This risk factor refers to the mother or father’s involvement with Child and Family Services for child protection services related to suspected or substantiated abuse of other children. The prevalence of this risk factor is significantly lower in the region than that in Manitoba as a whole. Maternal Childhood Abuse This risk factor refers to the mother’s self-reported history of child abuse. The prevalence of this risk factor is significantly lower in the region than that in Manitoba as a whole. Paternal Child Abuse History This risk factor refers to the father’s self-reported history of child abuse. The prevalence in the region of this risk factor is not significantly different to that in Manitoba as a whole. Parental Criminal Activity This risk factor refers to the reported criminal activity of the mother or father. The prevalence in the region of this risk factor is not significantly different to that in Manitoba as a whole. Families First staff indicate that the families they work with may face stigma and social isolation. These clients may have difficulty accessing specialists, mental health services, social work services, dental care, vision care, and medical care. Sometimes, families may have difficulty meeting their basic needs. This population could benefit from greater advocacy on their behalf and better access to social supports. PG:198CHAPTER7:PUBLICHEALTH ParentChildCoalitions Parent Child Coalitions bring together individuals and organizations that have a vested interest in healthy families and optimal child development, and that are interested in working with parents, caregivers, and service providers to support families and their children. Coalitions support existing programs and activities within communities and initiate new activities that reflect each community’s diversity and unique needs. There are two Parent Child Coalitions within the region; The Promise Years Parent Child Coalition which covers the south part of the region, and The Assiniboine North Parent Child Coalition that covers the north part of the region. DevelopmentalScreening One of the most common concerns among parents of young children is the development of their child. Public health nurses in the Assiniboine region offer developmental screening at an early age to address any concerns that may revolve around the development of crawling or walking, feeding issues, behaviour concerns, or sensory issues (when the child does not like to be touched or is always running into things, will only eat certain foods, will not explore new textures in the environment, seems to overreact or under-react to sounds, etc.). Many developmental delays, if caught early enough, can be corrected and will not be a problem later in the child's life. However, when left untreated, these delays may affect the child's education, social life, and general health and happiness. The screens are offered at Well Baby/Child Health Clinics and pre school wellness fairs in conjunction with the parent child coalition. Children'sTherapyInitiative The goal of the ARHA Children’s Therapy Initiative is the provision of therapy services including occupational therapy, physiotherapy, speech and language pathology, and audiology for children in the region from birth to when they leave school. Therapy services are available to assist children in reaching their full potential through assessment and intervention of identified concerns in the area of hearing, speech, language, movement, learning, self-care, and social development. Services are provided using a child/family centered team approach which may include assessment, direct intervention, consultation, education, specialized equipment, and environmental adaptations. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:199 UnifiedReferralIntakeSystem(URIS) The Unified Referral and Intake System (URIS) is a program offered in the region aimed at providing support for children with designated health care needs while they are attending school, licensed child care, or receiving respite services. A child may be eligible for URIS services if they have any of the following health care needs; asthma, diabetes, seizures, life-threatening allergies, a cardiac condition, a bleeding disorder, steroid dependence, or if they require gastrostomy care, ostomy care, intermittent catheterization, pre-set oxygen, or oral/nasal suctioning. A registered nurse works with the parent/guardian to develop a health care plan and an emergency response plan to meet the child’s specific health care need. The registered nurse is also involved in the provision of training to staff (i.e. school educators, bus drivers, child care attendants, respite providers) around the child’s health care needs. The registered nurse will then monitor personnel involved with the child as necessary to ensure competencies are maintained and perform assessments and update health care plans annually. In January of 2010 there were plans in place for 108 medical interventions in childcare facilities and 843 in schools within the region. Table7.8URISInterventions20072010byHealthCareNeed School ChildcareFacility Jun2008 Jun2009 Jan2010* Jun2008 Jun2009 Jan2010* Asthma 606 535 550 59 63 618 Anaphylaxis 121 147 147 27 23 120 SeizureDisorder 56 68 56 12 15 59 CardiacCondition 21 29 36 ** ** 23 Diabetes 30 33 28 ** ** 31 Other 29 29 26 ** ** 34 *dataisfromyeartodate**SuppressedduetosmallnumbersSOURCE:URISPROGRAM2010 PG:200CHAPTER7:PUBLICHEALTH Immunization Immunization is a health protection intervention to initiate or increase resistance against infectious disease. It is arguably the single most important public health achievement in the past century as infectious diseases have dropped from being the leading cause of death a century ago to accounting for less than 5% of the deaths in Canada today. The majority of early childhood immunizations are given through Child Health Clinics. These clinics, held by public health nurses, provide an opportunity for assessment of the child’s health and development as well as providing education and anticipatory guidance about infant feeding and injury prevention. Staff have indicated that sometimes they do not have enough clinic time, with no available appointment times to offer. Some physician clinics provide immunizations for children. Once children reach school-age, immunizations are given through the school system, with some exceptions on an individual basis. Adult immunizations may be given in the public health office and are offered by some physician clinics. The recommended immunization schedule for children and adults is published by Manitoba Health and is a list of the immunizations recommended at certain ages. When an individual has received all the immunizations recommended for their age group they are considered ‘complete for age’. Obtaining and monitoring immunization status can be a challenge if families have to move often or when individuals or families come from a different country without a record of immunizations given previously. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:201 ChildhoodImmunization The Manitoba immunization schedule for infants up until the age of one includes diphtheria, pertussis, tetanus, polio (DaPTP) and Haemophilus influenzae B (HiB). Figure7.11CompleteImmunizationRatesforInfantsAged1Year(sexadjusted) Born19982000 Born200305 MBAvg19982000 MBAvg200305 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood South Mid North Manitoba 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% SOURCE:MCHPCHILDHEALTHATLAS2008 The region’s immunization rate for infants at age one was significantly higher than the provincial average in both time periods at 87.8% and 86.9% respectively compared to the Manitoba averages of 84.6% and 82.5% for the same time periods. In rural areas, there is a significant relationship between area level income and rates of immunization for infants at age one, with the highest income area having much higher rates (87.2%) than the lowest income area (67.8%) PG:202CHAPTER7:PUBLICHEALTH Immunizations required by two year olds include additional doses of DaPTP and HiB, as well as the measles, mumps, and rubella (MMR) vaccine. Pneumococcal conjugate 7 valent and Varicella were introduced in 2004 and are not included in this data. The immunization rates for 2 year olds in the region dropped significantly between the two time periods (from 77.6% in 1997-99 to 72.9% in 2002-04) and are now not significantly different to the provincial average. Immunizations that required four doses (DaPTP and HiB) contributed most to this decline. As with one year immunization rates, area-level income is significant with rates decreasing as area-level income decreases. Figure7.12CompleteImmunizationRatesforChildrenAged2Years(sexadjusted) Born199799 Born200204 MBAvg199799 MBAvg200204 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood South Mid North Manitoba 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% SOURCE:MCHPCHILDHEALTHATLAS2008 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:203 Immunizations required by seven year olds include additional doses of those vaccines required by two year olds. In both time periods, the region’s rate of immunization was significantly higher than the provincial average at 83.4% for those born between 1992 and 1994 and 88.3% for those born between 1997 and 1999, compared to the provincial averages of 74.2% and 76.4% respectively. In contrast to the rates for two year olds, the immunization rates rose significantly between the two time periods due to increases in rates for the polio and HiB vaccines. As with one and two year old immunization rates, seven year old rates are significantly related to area-level income, however in the second time period this relationship was less noticeable and the gap between the highest income areas and the lowest decreased. This was primarily driven by the increase in immunization rates for the lowest income areas. Figure7.13CompleteImmunizationRatesforChildrenAged7Years(sexadjusted) Born199294 Born199799 MBAvg199294 MBAvg199799 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood South Mid North Manitoba 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% SOURCE:MCHPCHILDHEALTHATLAS2008 PG:204CHAPTER7:PUBLICHEALTH The region’s immunization rates are again significantly higher than the provincial average in both cohorts (76.3% and 71.4% compared to 66.9% and 62.4%), however, there was a considerable drop in the more recent rates. This decline was due to lower rates of MMR immunization, and the relatively low uptake of the Hepatitis B vaccine which was introduced for the second cohort and not required for the first. As was the case with all other age group immunization rates, the rates for 11 year olds are significantly related to area-level income with the lowest rates appearing in the lowest income areas. Figure7.14CompleteImmunizationRatesforChildrenAged11Years(sexadjusted) Born198890 Born199395 MBAvg198890 MBAvg199395 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood South Mid North Manitoba 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% SOURCE:MCHPCHILDHEALTHATLAS2008 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:205 A summary of childhood immunization rates for the Assiniboine Regional Health Authority compared to Manitoba is shown in Table 7.9. The table shows rates for two distinct cohorts in each age group to indicate how rates have changed over time. In every age group cohort2 is made up of children born later (and hence receiving immunizations later) than those in cohort1. Table7.9ImmunizationRates‘CompleteforAge’111 COMPLETEAGE1 COMPLETEAGE2 COMPLETEAGE7 COHORT1 COHORT2 COHORT1 COHORT2 COHORT1 COHORT2 COMPLETEAGE11 COHORT1 COHORT2 Assiniboine 87.8% 86.9% 77.6% 72.9% 83.4% 88.3% 76.3% 71.4% Manitoba 84.6% 82.5% 72.3% 69.6% 74.2% 76.4% 66.9% 62.4% SOURCE:MCHPCHILDHEALTHATLAS2008 A summary of childhood immunization in the region indicates the following; In all cases other than the second cohort at age 2, the regional immunization rates are significantly higher than the provincial averages. Other than ‘complete for age 7’ (where there has been a significant increase) the regional (and provincial) immunization rates have shown a significant decrease over time between the first cohort and the second cohort. The reasons for this are explained in the detailed look at each age group preceding this summary. In all cases there is a significant relationship between area-level income and immunization rates with the lowest income areas having the lowest rates. Whilst the region’s immunization rates are mostly higher than the provincial average, it should be noted that the Public Health Agency of Canada maintains specific targets for childhood immunization rates that are vaccine specific but range from 95-99%, considerably higher than any rates achieved in the region to date. All childhood immunization rates given are sexadjusted to allow for meaningful comparisons between regional rates and other regional health authorities. The Sex Differencesreportindicatedthattherewerenosignificantvariationsinimmunization rates for male and females at any age group for childhood vaccinations in the AssiniboineRHA. PG:206CHAPTER7:PUBLICHEALTH AdultImmunization Adult immunizations on the Manitoba Health immunization schedule is confined to residents aged 65 and over who are recommended to have an annual influenza (flu) immunization and a ‘once in a lifetime’ pneumococcal immunization. Influenza immunization rates in the region were significantly lower than the Manitoba average in 2000/01, but have since improved, and are not dissimilar to the Manitoba average in 2005/06. Figure7.15InfluenzaImmunizationRatesforResidentsaged65+Years(ageandsex adjusted)2000/01and2005/06 2000/01 2005/06 MBAvg2000/01 MBAvg2005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0% 10% 20% 30% 40% 50% 60% 70% 80% SOURCE:MCHPRHAINDICATORSATLAS2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:207 Cumulative pneumococcal immunization rates for the region, whilst off to a slow start (the region’s rate was lower than the provincial average in the first period), are now in line with the provincial average. This immunization is a one time vaccination for all residents ages 65 and over that was introduced in April of 2000, which explains the significant increase between the two time periods as more and more seniors receive the immunization. Figure7.16CumulativePneumococcalImmunizationRatesforResidentsaged65+ Years(ageandsexadjusted)2000/01and2005/06 byendof2000/01 byendof2005/06 MBAvg2000/01 MBAvg2005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0% 10% 20% 30% 40% 50% 60% 70% 80% SOURCE:MCHPRHAINDICATORSATLAS2009 Alladultimmunizationratesgivenareageandsexadjustedtoallowformeaningful comparisons between regional rates and other regional health authorities. The Sex Differencesreportindicatedthattherewerenosignificantvariationsinimmunization ratesformaleandfemalesforadultvaccinationsintheAssiniboineRHA. PG:208CHAPTER7:PUBLICHEALTH The Public Health Agency of Canada maintains specific targets for adult immunization rates set at 70% for influenza and 80% for pneumococcal. The region’s most recently reported rates of 64.3% (2005/06) for influenza and 58.3% (2005/06) for pneumococcal do not meet these national standards. TravelHealth In collaboration with Brandon Regional Health Authority, the region offers a comprehensive Travel Health program which provides; Information on all health risks specific to the country or region of travel, A vaccination service specific to travelling to foreign countries and adult immunizations, and Information about preventing travel related illnesses. The service is currently based in Brandon and in 2008/2009, 291 Assiniboine residents made use of the service. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:209 CommunicableDiseases As part of its role, the Public Health program of the Assiniboine Regional Health Authority is tasked with the prevention, management, and control of communicable diseases within the region as legislated under the Public Health Act of Manitoba. Amongst the most common are Salmonella, Shigella, rabies, West Nile virus, and verotoxogenic E. coli. Table7.10CommunicableInfectionsbyType(NewCases5yearaverage20022006) Verotoxogenic E.coli Salmonella Shigella Assiniboine 13.8 17.8 1.2 Manitoba 7.0 12.7 1.2 SOURCE:MANITOBAHEALTHCDC2008 Verotoxogenic E. coli is a strain of bacteria causing diarrhea that is usually transmitted by food, water, or from person to person. The Assiniboine Region reported 69 new cases of Verotoxogenic E. coli during the five-year period form 2002 through 2006. The number of infections varies from year to year, however the rates for the region are almost twice the provincial average despite the increased awareness of the E. coli bacteria which undoubtedly followed the Walkerton experience. Shigella is a bacterium that may cause acute illness with fever and gastrointestinal symptoms. There have been only 6 reported cases of Shigella in Assiniboine in the five year period from 2002-2006. Since 1998, the number of cases of Shigella in the province has been steadily decreasing. Salmonella is a bacterium that frequently causes fever and gastroenteritis. The Assiniboine region reported on average 17 new cases of salmonella per year during this time. The numbers have been variable from 2002 to 2006, ranging from 12 to 23 per year, but have been consistently high given our population. A closer examination of the geographic and demographic distribution of the infections could provide insight into potential contributors to the consistently high rate of infection. Education strategies to inform the public about the reservoirs of infection and mode of transmission of salmonella may help to reduce the numbers of infections. Rabies is viral disease that causes acute inflammation of the brain in humans and animals. It is transmitted by mammals, most commonly by a bite from an infected animal. It is fatal if left untreated. In 2008 public health nurses in the Assiniboine region investigated 92 possible rabies infections. PG:210CHAPTER7:PUBLICHEALTH West Nile virus is a relatively new disease in Manitoba. The virus is transmitted by mosquitoes. Most people who are bitten by an infected mosquito do not become ill and for those who do, the symptoms are usually mild. In some relatively rare cases, the virus causes serious illness and sometimes death. In 2007, there were a staggering 162 cases of West Nile in the Assiniboine region, equating to almost 28% of the cases in the province amongst only 5.7% of the population. Of the four human deaths associated with West Nile in 2007, only one occurred within our region. Table7.11WestNileCasesbyRegionalHealthAuthority2007 Non Neurological Asymptomatic Neurological Syndrome Syndrome Unclassified TOTAL Assiniboine 3 142 17 0 162 Brandon 0 65 6 1 72 Central 2 95 8 2 107 Interlake 1 38 5 1 45 NorthEastman 1 19 3 0 23 Parkland 0 14 3 0 17 SouthEastman 1 25 2 1 29 Winnipeg 1 103 28 0 132 Manitoba 9 501 72 5 587 SOURCE:MANITOBAHEALTHCDC2008 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:211 SexuallyTransmittedInfections The most common sexually transmitted infections are chlamydia, gonorrhea and HIV or human immunodeficiency virus. Table7.12SexuallyTransmittedInfectionsbyTypebyGender(5yearaverage2002 2006,rateper1,000) MaleRate/1,000 FemaleRate/1,000 Chlamydia Gonorrhea Chlamydia Gonorrhea Assiniboine 0.61 0.05 1.22 0.07 Manitoba 1.61 0.64 2.89 0.50 SOURCE:MANITOBAHEALTHCDC2008 Chlamydia is a sexually transmitted infection that is associated with infertility and ectopic pregnancy. The region’s rate for 2002-2006 is 0.61/1,000 for males and slightly higher in females at 1.22/1,000. This equates on average to around 60 cases per year, two thirds of which are in women. In both men and women, the rate is less than half the provincial average. Gonorrhea is a sexually transmitted infection that if left untreated, can lead to infertility and neonatal or adult blindness. The region’s rate for 2002-2006 is 0.05/1,000 for males and slightly higher in females at 0.07/1,000. This equates on average to around 4 cases per year. In both men and women, the rate is insignificant when compared to the provincial average. HIV (human immunodeficiency virus) is the virus that causes acquired immune deficiency syndrome. Assiniboine reported 4 new cases of HIV from 2002-2006. The number of new cases of HIV in Manitoba per year has been variable, ranging from 70 to 115 in the same time period. PG:212CHAPTER7:PUBLICHEALTH ChapterHighlights Access to prenatal care early in pregnancy is essential for optimal outcomes for mothers and infants, but some women delay seeking that care. Teen pregnancy rates remain among the lowest in the province, suggesting a successful Reproductive Health program. Providers report increasingly complex care needs among children and families. Immunizations rates for children remain high compared to the Manitoba average, although there have been some decreases in immunization rates over time. Even though immunization rates among children in the Assiniboine region have been high, they have still not reached national targets. The rates of some communicable diseases in the region have been higher than expected. Rates of sexually transmitted infections among Assiniboine residents remain low. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:213 Chapter8:MentalHealth The region’s Community Mental Health program provides a welcoming, client-based, recovery oriented service for those who are experiencing difficulty in coping with a wide range of mental health difficulties including co-occurring addictions. Services are voluntary (except as outlined under the Mental Health Act) and provided as determined appropriate and available in each individual’s circumstance. A continuum of Mental Health Services exists, ranging from community-based peer support and professional services, to emergency response and hospital-based services for very acute needs. Community mental health is a decentralized program of mental health care and other services for people with mental illnesses. Community-based care is designed to supplement and decrease the need for more costly inpatient mental health care delivered in hospitals. Community mental health care is considered to be more accessible and responsive to local needs because it is based in a variety of community settings rather than aggregating and isolating patients and patient care in central hospitals. Mental health services are provided by clinicians, who specialize in services specific to children and adolescents, adults, and the elderly. Typically, these clinicians are trained in professions such as psychiatry, psychology, social work, psychiatric nursing, and occupational therapy. Services are provided in various community and hospital settings across the Region. Adult psychiatric inpatient services are provided for Assiniboine RHA clients through the Brandon RHA. According to staff, mental health clients are often stigmatized, with people only seeing the illness and not the whole person. These clients can also suffer from other chronic diseases, adverse effects from medications, and relationship issues. Mental health clients may have difficulty accessing proctors, support groups, vocational training, foot care, dental care, therapy services, medical care (including psychiatry), social workers, and psychologists. Staff feel that physicians and nurses could benefit from education on caring for mental health clients. PG:214CHAPTER8:MENTALHEALTH Child&AdolescentServices This program provides a range of services to persons under the age of 18 years and their family where the mental and emotional health of the child is causing significant disruption in the life of the child and/or the family. Services offered by child and adolescent community mental health workers could include: Emergent response Intake services for new service requests, crisis intervention and information Assessment and treatment planning in collaboration with family Goal oriented treatment Consultations with psychiatry in conjunction with the family physician Collaborative treatment with addiction services for individuals with co-occurring addictions and mental health difficulties Referrals to other community and medical services Consultation services Education for clients, family members, care providers, and the community Consultation with other service providers in the community Staff mentioned the need for greater attention to the effects of relationships such as childhood sexual abuse, multiple foster placements, and long-term trauma. It was felt that parents need to be empowered and educated about children’s issues. The Child and Adolescent Treatment Centre (located in Brandon) provides mental health services to children, adolescents, and their families. Services available to Assiniboine residents include the Crisis Stabilization Unit (CSU) which focuses on alleviating the crisis and returning the client to the community. Services provided include: multidisciplinary team assessments, individual treatment, group and family therapy, community transition, and consultation with community resources. The Early Intervention Service (EIS) is a community service for individuals aged 15-30. The overall goal of EIS is to improve the mental health and quality of life of young people with psychosis and bi-polar disorder through early identification and treatment. EIS includes assessment, treatment, individual, and family support. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:215 Child and Adolescent Service caseloads have remained relatively stable from 2006/07 to 2008/09. Table8.1ChildandAdolescentServicesProgramStatistics2006/072008/09 2006/2007 2007/2008 2008/2009 ActiveCases 193 217 203 IntakeCases N/A 539 530 AdmissionstoCATC 57 69 68 SOURCE:ARHAMENTALHEALTHPROGRAM2010 AdultServices The Adult Community Mental Health Counselling Services offer a range of treatments for the adult population of Assiniboine RHA who are dealing with mental health and/or addiction difficulties. Services provided through adult community mental health workers could include: Emergent response Intake Services for new service requests, crisis intervention and information Assessment and Treatment planning Goal oriented individual or group counselling Consultations with psychiatry in conjunction with the family physician Collaborative treatment with addiction services for individuals with co-occurring addictions and mental health difficulties Referrals to other community and medical services Referrals to and collaboration with self help organizations Community counselling following traumatic events Consultation services Education for clients, family members, care providers. and the community Consultation with other service providers in the community The Centre for Adult Psychiatry (CAP) (located in Brandon) is a 25-bed facility designated under the Mental Health Act of Manitoba. The Centre delivers acute, comprehensive services to adults between the ages of 18-64, who are experiencing a psychiatric illness and/or severe psychosocial crisis. The facility offers a range of services to Assiniboine residents including diagnosis and treatment of mental illnesses, assessment, crisis stabilization, short-term treatment/intervention, psychological testing/assessment, medication reviews and/or adjustments, and individual and family counselling. It has a comprehensive discharge planning service including transitional programming and referral to community resources. PG:216CHAPTER8:MENTALHEALTH Whilst the number of active cases in the Adult Mental Health program has remained relatively stable, there has been an 18% increase in the number of intakes from 2007/082008/09 and a 19% decrease in the number of admissions to CAP between 2006/07 and 2008/09. Table8.2AdultMentalHealthServicesProgramStatistics2006/072008/09 2006/2007 2007/2008 2008/2009 ActiveCases 362 385 376 IntakeCases N/A 1,220 1,439 AdmissionstoCAP 201 174 163 SOURCE:ARHAMENTALHEALTHPROGRAM2010 MentalHealthServicesfortheElderly Mental Health Services for the Elderly (MHSE) is a team of mental health professionals provided through the Brandon RHA with special training and experience in working with elderly people who have mental health care needs. They provide assessments, consultation, and care for mental health problems commonly associated with aging including depression, dementia, and anxiety or other psychiatric conditions for residents of the Assiniboine region. The Centre for Geriatric Psychiatry (CGP) is a 22 bed acute care unit located at the Brandon Regional Health Centre that provides specialized assessment and short term treatment for individuals 65 years and over who are experiencing difficulties with day to day functioning due to mental health problems. The number of Assiniboine residents being admitted to CGP has remained stable for the three year period 2006/07-2008/09 at around 89 admissions per year on average. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:217 ProctorServices Proctor services in the region provide local supports to clients suffering from mental illness living in the community. They assist in ensuring wellness and maintenance of health and the early identification of relapse reducing the need for the admission of long term mentally ill clients to acute care centres. WestmanCrisisServices Westman Crisis Services works with adults in the Brandon and Assiniboine regions who are in a mental health or psychosocial crisis. They offer two services: the Crisis Stabilization Unit and the Mobile Crisis Unit. These two units work together to provide residents of the region with the help they need when dealing with a mental health crisis. The Crisis Stabilization Unit (CSU) has eight beds in Brandon for residents needing a place to stay whilst receiving care. Members of the team help to develop a plan which can include crisis intervention, help to adjust to medications, and help with social and coping skills, in order to deal with the current situation and prevent further crisis. The Mobile Crisis Unit (MCU) is a community-based service where staff will meet with people in their own home, or another suitable place, to offer assistance to residents dealing with a mental health crisis. PG:218CHAPTER8:MENTALHEALTH MentalHealthPromotion The ARHA Mental Health Team is very active in prevention and promotion activities in the region. Numerous activities have been conducted in the community, most recently in the areas of mental health awareness, suicide prevention, and body image/awareness. For several years, the Assiniboine region has partnered with school divisions and communities to offer innovative mental health awareness activities, including entertaining public awareness events, and connecting with community members at local coffee shops. Applied Suicide Intervention Skills Training (ASIST) is a two-day, skill-building workshop that prepares caregivers of all kinds to provide suicide first aid interventions. SafeTALK is a half-day training session that provides anyone over the age of 15 with the skills necessary to identify persons with thoughts of suicide and to connect them to suicide first aid resources. Community mental health workers believe that it is important to continue suicide prevention activities. Mental Health First Aid is a 2 day course which teaches the signs and symptoms of common mental health problems and crisis situations, a basic five step mental health first aid model, information about effective interventions and treatments, and how to access help and resources. Table8.3MentalHealthPromotionActivities BodyImage/Awareness MentalHealth–Makeit YourBusiness ASIST SafeTALK MentalHealthFirstAid MentalIllness AwarenessWeek Numberof Sessions Numberof Participants TimePeriod 43 1,327 2007/082008/09 43 1,341 20082009 32 570 20032008 12 189 20082009 7 113 20082009 5 1,345 20072009 SOURCE:ARHAMENTALHEALTHPROGRAM2010 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:219 GeneralMentalHealth Mental health has a strong influence on health outcomes. Long term exposure to stressful circumstances can be damaging to one’s health, causing people to be more vulnerable to chronic health conditions. The general mental health scale is a derived measure from the SF-36 questionnaire, addressing overall mental health on a scale of 0-100 (higher is better). Based on the distribution of scores, three groups are created with approximately one third of the respondents in each group. The SF36 (ShortForm 36) is a questionnaire used in the Canadian Community Health Surveydesignedtoevaluatethehealthofanindividualineightdistinctcategories.Each categoryisgivenascoreof0100witheachquestiongivenequalweight.Thecategories are: vitality, physical functioning, bodily pain, general health perceptions, physical role functioning,emotionalrolefunctioning,socialrolefunctioning,andmentalhealth. The Canadian Community Health Survey (CCHS) is conducted by Statistics Canada to provide regular and timely cross–sectional estimates of health determinants, health status,andhealthsystemutilizationfor136healthregionsinCanada.Thesurveyexcludes populations living on Indian Reserves, on Canadian Forces Bases, and in some remote areas,andthosenotlivinginhouseholds. The Assiniboine region has a relatively high percentage in the top two groups showing that our residents’ responses indicated that they had generally good mental health compared to the province as a whole. The North 1 and North 2 districts showed slightly higher percentages in the lower category than other districts in the region. PG:220CHAPTER8:MENTALHEALTH Figure8.1SF36GeneralMentalHealthScaleAged12+(AgeandSexAdjustedCCHS 20032005) Low(079) Medium(8091) High(92100) SouthEastman 22% 35% 43% Central 20% 37% 43% Assiniboine 22% Brandon 23% Winnipeg 27% Interlake 28% NorthEastman 27% Parkland 28% 32% 33% 43% 35% 32% 48% 40% 32% 45% 35% 25% 10% 44% 33% 22% 0% 40% 35% 27% Manitoba 47% 32% 21% North 41% 25% 28% Mid 35% 33% Burntwood RuralSouth 39% 36% 19% NorMan 47% 20% 30% 40% 40% 50% 60% 70% 80% 90% 100% SOURCE:MCHPRHAINDICATORSATLAS2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:221 SelfPerceivedStress(LifeandWork) Community members, partners, and staff expressed concern about stress and the need for stress management strategies. This was also noted during the last community health assessment. When under stress, some people may turn to unhealthy coping strategies such as drugs and alcohol. Staff and partners provided suggestions for assisting residents to learn healthy ways of coping with stress. Figure8.2Life(L)Ages15+andWork(W)Ages1575Related,SelfPerceivedStress (AgeandSexAdjustedCCHS20012005) NONE/LOW SouthEastman(L) 35% Central(L) 34% Assiniboine(L) MEDIUM HIGH 20% 45% 21% 45% 19% 42% 39% RuralSouth(L) 36% Manitoba(L) 35% 44% 21% SouthEastman(W) 34% 44% 22% Central(W) 33% Assiniboine(W) 34% 44% 22% RuralSouth(W) 33% 44% 22% Manitoba(W) 10% 23% 44% 28% 41% 31% 0% 20% 44% 20% 30% 40% 50% 60% 70% 80% 90% 100% SOURCE:MCHPRHAINDICATORSATLAS2009 PG:222CHAPTER8:MENTALHEALTH Questions are asked as part of the Canadian Community Health Survey regarding the level of stress experienced by residents. They are given the opportunity to respond that their work or life in general is ‘not at all stressful’, ‘not very stressful’, ‘a bit stressful’, ‘quite a bit stressful,’ or ‘extremely stressful’. The responses were then grouped into three categories and the results for both life and work stress are shown in Figure 8.2. Self-perceived stress levels for residents of the region appear to be comparable, if not lower, than the province as a whole particularly when it comes to work related stress. The East 2 shows the lowest rates of both life and work related stress and East 1 the highest in both categories. MentalIllnessTreatmentPrevalence This section looks at the prevalence of mental illness disorders amongst residents of the Assiniboine region and their health care service utilization. Each of six specific disorders are discussed separately as well as the service use of those residents having one or more of what are referred to as cumulative mental illness disorders compared to those having a disorder not within the cumulative disorders group; other disorder, and those having no disorder. Thecumulativementaldisordersgroupreferstothosepeoplehavingoneormoreof the following conditions: depression, anxiety disorder, substance abuse, schizophrenia,andpersonalitydisorder. The other disorder group refers to those having a mental illness disorder not within thecumulativedisordersgroupe.g.dementia. Thenodisordergroupreferstothosepeoplewhohavenodiagnosesforany mental conditionwiththetimeframespecified. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:223 The crude treatment prevalence of residents (the number being treated for the condition) in the region are shown in Table 8.4, they show a significant increase in the number of residents suffering from various mental illness disorders across the two time periods studied. The increase is most apparent in the number of residents suffering from depression or anxiety. This is despite a decline in the overall population between the two time periods. Table 8.4 Treatment Prevalence of Mental Illness Disorders in the Assiniboine RHA (Aged10+)1996/97–2001/02and2001/022005/06(CrudePercent) PersonalityDisorders SubstanceAbuse Schizophrenia Dementia Depression Anxiety NumberObserved Crude PerYear Percent 1996/972000/01 364 0.54 2,775 4.13 404 0.60 2,073 9.36 9,724 14.46 3,192 4.75 NumberObserved Crude PerYear Percent 2001/022005/06 396 0.60 2,751 4.16 404 0.61 2,025 9.28 10,895 16.49 3,509 5.31 SOURCE:MCHPRHAINDICATORSATLAS2009 The age and sex adjusted treatment prevalence (the number of residents seeking treatment adjusted for the population of Manitoba) has increased for almost every mental illness disorder between the two time periods. Only in the rate of residents seeking treatment for dementia has there been a modest decline. The most noticeable increase is in the number of residents seeking treatment for depression which has gone up from 14.39% to 16.36%. In crude numbers, an average of almost eleven thousand residents per year would have been treated for depression between 2001/02 and 2005/06. PG:224CHAPTER8:MENTALHEALTH Figure 8.3 Treatment Prevalence of Mental Illness Disorders in the Assiniboine RHA (Aged10+)1996/97–2001/02and2001/022005/06(AgeandSexAdjusted) 1996/972000/01 2001/022005/06 0.55% Personality Disorders 0.61% 4.28% Substance Abuse 4.32% 0.57% Schizophrenia 0.59% 8.32% Dementia 8.10% 14.39% Depression 16.36% 4.86% Anxiety 5.42% 0% 5% 10% 15% SOURCE:MCHPRHAINDICATORSATLAS2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:225 CumulativeDisorders The treatment prevalence of residents in the cumulative mental disorders group is significantly lower than that of Manitoba as a whole in both time periods. It has however increased markedly between the two time periods. District level data shows a higher prevalence closer to the Manitoba average in both the West 1 and North 2 districts. Females in this group are more likely to suffer/seek treatment and the prevalence in the second time period equates to 13,484 individuals. The cumulative mental disorders group refers to those people having one or more of the following conditions: depression, anxiety disorder, substance abuse, schizophrenia, and personality disorder. Figure8.4TreatmentPrevalenceof‘CumulativeDisorders’(Aged10+)1996/97– 2001/02and2001/022005/06(AgeandSexAdjusted) 1996/972000/01 2001/022005/06 MBAvg1996/972000/01 MBAvg2001/022005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0% 5% 10% 15% 20% 25% 30% SOURCE:MCHPRHAINDICATORSATLAS2009 PG:226CHAPTER8:MENTALHEALTH AnxietyDisorders Anxiety disorder is a term covering several different forms of abnormal, pathological anxieties, fears, and phobias e.g. separation anxiety, obsessive-compulsive disorder etc. The treatment prevalence of anxiety disorders in the Assiniboine region is significantly lower than that of Manitoba as a whole in both time periods. It has however increased markedly between the two time periods. District level data shows a higher prevalence closer to the Manitoba average in the West 1 district. Female residents are more likely to suffer/seek treatment for anxiety disorders and the prevalence in the second time period equates to 3,509 individuals. Figure8.5TreatmentPrevalenceofAnxietyDisorders(Aged10+)1996/97–2001/02 and2001/022005/06(AgeandSexAdjusted) 1996/972000/01 2001/022005/06 MBAvg1996/972000/01 MBAvg2001/022005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0% 2% 4% 6% 8% 10% SOURCE:MCHPRHAINDICATORSATLAS2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:227 Dementia Dementia is the progressive decline in cognitive function due to damage or disease in the body beyond what might be expected from normal aging. The treatment prevalence of dementia in the Assiniboine region is significantly lower than that of Manitoba as a whole in both time periods. It has not changed to any significant degree between the two time periods. District level data shows a higher prevalence closer to the Manitoba average in the West 1 and East 1 districts. Female residents are more likely to suffer/seek treatment for dementia and the prevalence in the second time period equates to 2,025 individuals. Figure8.6TreatmentPrevalenceofDementia(Aged10+)1996/97–2001/02and 2001/022005/06(AgeandSexAdjusted) 1996/972000/01 2001/022005/06 MBAvg1996/972000/01 MBAvg2001/022005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% SOURCE:MCHPRHAINDICATORSATLAS2009 PG:228CHAPTER8:MENTALHEALTH Depression The treatment prevalence of depression in the Assiniboine region is significantly lower than that of Manitoba as a whole in both time periods. It has however increased markedly between the two time periods. District level data shows a higher prevalence closer to the Manitoba average in the North 1, North 2 and East 1 districts. Female residents are more likely to suffer/seek treatment for depression and the prevalence in the second time period equates to 10,895 individuals. Mental health staff felt that the issue of men and depression needs more attention. Figure8.7TreatmentPrevalenceofDepression(Aged10+)1996/97–2001/02and 2001/022005/06(AgeandSexAdjusted) 1996/972000/01 2001/022005/06 MBAvg1996/972000/01 MBAvg2001/022005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0% 5% 10% 15% 20% 25% SOURCE:MCHPRHAINDICATORSATLAS2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:229 PersonalityDisorders A personality disorder is generally defined as an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it. The treatment prevalence of personality disorders in the Assiniboine region is significantly lower than that of Manitoba as a whole in both time periods. It has not changed to any significant degree between the two time periods. District level data shows a higher prevalence and a significant increase over time in the North 2 and East 1 districts. Female residents are more likely to suffer/seek treatment for personality disorders and the prevalence in the second time period equates to 396 individuals. Figure 8.8 Treatment Prevalence of Personality Disorders (Aged 10+) 1996/97 – 2001/02and2001/022005/06(AgeandSexAdjusted) 1996/972000/01 2001/022005/06 MBAvg1996/972000/01 MBAvg2001/022005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0.00% 0.25% 0.50% 0.75% 1.00% 1.25% 1.50% SOURCE:MCHPRHAINDICATORSATLAS2009 PG:230CHAPTER8:MENTALHEALTH Schizophrenia Schizophrenia is a psychiatric diagnosis that describes a mental disorder characterized by abnormalities in the perception or expression of reality. The treatment prevalence of schizophrenia in the Assiniboine region is significantly lower than that of Manitoba as a whole in both time periods. It has not changed to any significant degree between the two time periods. District level data shows a higher prevalence closer to the Manitoba average in the North 2 district. Both male and female residents are equally likely to suffer/seek treatment for schizophrenia, however there is a correlation between neighbourhood income level and treatment prevalence with the highest prevalence occurring in the lowest income areas and gradually decreasing as neighbourhood income levels increase. For the Assiniboine region, the prevalence in the second time period equates to 404 individuals. Figure8.9TreatmentPrevalenceofSchizophrenia(Aged10+)1996/97–2001/02and 2001/022005/06(AgeandSexAdjusted) 1996/972000/01 2001/022005/06 MBAvg1996/972000/01 MBAvg2001/022005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0.00% 0.25% 0.50% 0.75% 1.00% 1.25% 1.50% SOURCE:MCHPRHAINDICATORSATLAS2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:231 SubstanceAbuse The treatment prevalence of substance abuse in the Assiniboine region is significantly lower than that of Manitoba as a whole in both time periods. It has not changed to any significant degree between the two time periods. District level data shows a higher prevalence closer to the Manitoba average in the North 1, North 2, and West 1 districts. Male residents are more likely to suffer/seek treatment for substance abuse. For the Assiniboine region, the prevalence in the second time period equates to 2,751 individuals. Figure8.10TreatmentPrevalenceofSubstanceAbuse(Aged10+)1996/97–2001/02 and2001/022005/06(AgeandSexAdjusted) 1996/972000/01 2001/022005/06 MBAvg1996/972000/01 MBAvg2001/022005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% SOURCE:MCHPRHAINDICATORSATLAS2009 PG:232CHAPTER8:MENTALHEALTH It may be important to note that this only reflects those who have been treated for substance use, and does not capture all of the people who may have substance abuse issues. Partners expressed concern about the culture of drinking in many communities which encourages drinking to intoxication. Community members and youth are concerned about drug and alcohol use in Assiniboine communities. Substance Abuse and Addictions services are provided to residents of the Assiniboine region primarily through the Addictions Foundation of Manitoba. The Addictions Foundation of Manitoba has a provincial mandate to provide prevention, education, and rehabilitation programs related to chemical misuse, chemical dependency, and problem gambling for individuals and communities. Mental health staff mentioned the value of having residential beds for clients with co-occurring disorders. There are linkages between addiction services and the Community Mental Health program through the Co-occurring Disorders Initiative, which aims to improve the capacity to provide service to individuals who have co-occurring mental health and substance use disorders. The goal of this model is to develop a system of care that provides comprehensive, continuous and integrated services. Through this initiative: Services have reviewed policies and practices to provide a welcoming and hopeful environment for individuals with co-occurring disorders, Clients entering most parts of either the addictions or mental health systems are screened for co-occurring disorders, Individuals who screen positively for a co-occurring disorder will receive a comprehensive clinical assessment, and With consent, individuals who have been assessed as having a co-occurring disorder will have an integrated treatment plan. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:233 HealthCareUtilization Despite the relatively low treatment prevalence rates for mental illness disorders in the Assiniboine region (compared to the Manitoba average), the health care utilization amongst this group is in general very high. AllCauseAcuteCareHospitalSeparationRates Acute care hospitalizations rates for men in the region are amongst the highest in the province for both those with cumulative disorders and those without. The rate for those with cumulative disorders (353/1,000) is 2.5 times that for those with no disorders (138/1,000) and both values are significantly higher than the Manitoba average. Figure8.11AllCauseHospitalSeparationRatesforMales(Aged10+)Withand WithoutCumulativeDisorders1997/98–2001/02(AgeAdjusted) withdisorder nodisorder MBavgwithdisorder MBavgnodisorder SouthEastman Brandon Central Assiniboine Parkland Interlake NorthEastman Burntwood Churchill NorMan RuralSouth North Winnipeg Manitoba 0 100 200 300 400 SOURCE:MCHPPATTERNSOFREGIONALMENTALILLNESSDISORDER2004 500 PG:234CHAPTER8:MENTALHEALTH A similar pattern can be seen for separation rates amongst females in the region although the rate for those with disorders is only twice that of those with no disorders. The separation rates for females for both groups are significantly higher than those of males. Figure8.12AllCauseHospitalSeparationRatesforFemales(Aged10+)Withand WithoutCumulativeDisorders1997/98–2001/02(AgeAdjusted) withdisorder nodisorder 0 200 MBavgwithdisorder MBavgnodisorder SouthEastman Brandon Central Assiniboine Parkland Interlake NorthEastman Burntwood Churchill NorMan RuralSouth North Winnipeg Manitoba 100 300 400 500 600 700 800 SOURCE:MCHPPATTERNSOFREGIONALMENTALILLNESSDISORDER2004 The higher hospitalization rate for both females and males within the cumulative disorders group is not due primarily to hospitalizations for ‘mental illness’. Rates for all physical illness were near double for that group compared to those without mental health concerns. This would indicate that they tend to be ‘physically sicker’ than those without disorders. The ‘total burden’ placed on acute care hospitals attributable to mental illness is significant with 32.4% of all male separations and 43.3% of all female separations coming from the group with cumulative disorders. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:235 The percentage of hospital separations specifically for ‘mental illness’ is also amongst the highest in the province at 4.7% for all residents. Just over eleven percent (11.1%) of the separations attributed to those residents within the cumulative disorders group are specifically for a mental illness. Table8.5PercentageofAllCauseHospitalSeparationsforMentalIllness1997/98 2001/02 SouthEastman Brandon Central Assiniboine Parkland Interlake NorthEastman Burntwood Churchill NorMan RuralSouth North Winnipeg Manitoba Cumulative DisordersGroup 7.5% 12.5% 7.7% 11.1% 10.0% 7.3% 7.5% 8.0% 15.1% 8.9% 8.7% 8.4% 9.9% 9.4% Other AllResidents 1.4% 1.9% 2.5% 2.9% 2.7% 1.7% 2.0% 1.2% 0.8% 1.0% 2.3% 1.1% 1.6% 1.9% 3.1% 5.6% 3.2% 4.7% 4.3% 2.9% 3.1% 4.7% 6.9% 4.1% 3.7% 4.5% 4.4% 4.2% SOURCE:MCHPPATTERNSOFREGIONALMENTALILLNESSDISORDER2004 Within the cumulative disorders group the hospital separation rates are highest amongst females of the region and particularly high for those with personality disorders for both males and females. Table8.6AllCauseHospitalSeparationRatebyDisorder1997/98–2001/02(Age Adjusted) Depression Anxiety Assiniboine RuralSouth Manitoba 374 314 253 426 353 250 Assiniboine RuralSouth Manitoba 428 370 303 522 451 333 Substance Abuse Schizop hrenia Personality Disorder Other Cumulative None 708 563 453 227 202 151 353 306 248 138 122 102 1278 819 603 268 254 207 413 363 301 183 177 152 Males 436 376 332 404 347 345 Females 559 674 480 483 437 451 SOURCE:MCHPPATTERNSOFREGIONALMENTALILLNESSDISORDER2004 PG:236CHAPTER8:MENTALHEALTH PhysicianVisits In contrast to hospitalization rates, physician visits for mental illness in the Assiniboine region were significantly lower in both males and females than Manitoba as a whole. Females on average tended to have a higher visit rate and there was a significant relationship between neighbourhood income-level and visit rate with those from lower income areas making fewer visits. The average annual number of ambulatory visits to all physicians between 1997/98 and 2000/01 for which a mental illness was the cause of the visit is shown below. The data includes only those with some indication of a mental health disorder. Figure8.13PhysicianVisitsRatesforMentalIllnessDisorders1997/982001/02(Age Adjusted) males females MBavgmales MBavgfemales SouthEastman Brandon Central Assiniboine Parkland Interlake NorthEastman Burntwood Churchill NorMan RuralSouth North Winnipeg Manitoba 0.0 0.3 0.5 0.8 1.0 1.3 1.5 1.8 SOURCE:MCHPPATTERNSOFREGIONALMENTALILLNESSDISORDER2004 2.0 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:237 AntidepressantPrescriptionUse This section examines the use of antidepressant medication in the region including the use of SSRIs or Selective Serotonin Reuptake Inhibitors which have been linked with an increased risk of suicide. The figure shows the percent of residents with antidepressants in the given time period. The region 2000/01 to 2005/06 in common with the rest of antidepressant use are second only to Brandon in the higher than the Manitoba average. two or more prescriptions for shows a significant increase from Manitoba, however, its rates of later time period and significantly Figure8.14AntidepressantUse2000/01and2005/06(AgeandSexAdjusted) 2000/01 2005/06 MBAvg2000/01 MBAvg2005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% SOURCE:MCHPRHAINDICATORSATLAS2009 PG:238CHAPTER8:MENTALHEALTH The Sex Differences report of 2005 indicated that the rate of antidepressant use for both sexes was higher than the Manitoba average and that the use amongst females was roughly twice that for men in the region. A district level analysis showed that antidepressant use was particularly prevalent in the East 2 district of the region. An important aspect of the use of antidepressant medication is to ensure the client is seen on a regular basis immediately following the prescription. The region’s rate of follow-up (the percent of new depression patients who received at least three physician visits in the four month period immediately following the prescription) is significantly lower than that of Manitoba as a whole at just 54% in the first time period and 53% in the second time period compared to Manitoba rates of 59% and 58%. Unfortunately this rate of follow-up is particularly low at 45% in the East 2 district where antidepressant use is most prevalent. Figure8.15AntidepressantPrescriptionFollowUp1998/992000/01and2003/04 2005/06 1998/992000/01 2003/042005/06 MB1998/992000/01 MB2003/042005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood RuralSouth Mid North Manitoba 0% 10% 20% 30% 40% 50% 60% 70% SOURCE:MCHPRHAINDICATORSATLAS2009 80% ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:239 PrescriptionUseinChildren/Adolescents AntidepressantUse The use of antidepressant medications amongst the 0-19 age bracket in the region is significantly higher (15.1/1,000 residents compared to 10.5/1,000) than that of Manitoba as a whole. And whilst the Manitoba rate has dropped significantly between the two time periods, this is not the case for the Assiniboine region. Figure8.16AntidepressantPrescriptionUseRate/1,000Aged0191998/992000/01 and2003/042005/06(AgeandSexAdjusted) 2000/01 2005/06 MBAvg2000/01 MBAvg2005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood South Mid North Manitoba 0 5 10 15 20 25 SOURCE:MCHPCHILDHEALTHATLAS2008 The use of SSRIs or Selective Serotonin Reuptake Inhibitors as antidepressant medication (amongst the 10-19 age bracket) in the region is not significantly different from the Manitoba average. These drugs have been shown to have a potential increased risk of suicide associated with them. PG:240CHAPTER8:MENTALHEALTH PsychostimulantUse Psychostimulant medications are used to treat attention-deficit/hyperactivity disorder or ADHD in children. The rate of psychostimulant prescriptions increased dramatically in the 1990s and this pattern seems to have continued. The region’s rate of psychostimulant use increased from 21.5/1,000 to 28.8/1,000 from 2001/01 to 2005/06 making it the highest rate outside the urban centers of Brandon and Winnipeg. Males have much higher rates (more than three times) of psychostimulant use than females and in rural areas the use tended to be higher in areas with higher incomes. Figure8.17PsychostimulantPrescriptionUseRate/1,000Aged5192000/01and 2005/06(AgeandSexAdjusted) 2000/01 2005/06 MBAvg2000/01 MBAvg2005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood South Mid North Manitoba 0 5 10 15 20 25 30 35 SOURCE:MCHPCHILDHEALTHATLAS2008 40 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:241 ADHD (Attention-Deficit Hyperactivity Disorder) is the most common behavioural disorder identified in school age children. It is characterized by inattention, hyperactivity, and impulsivity. The prevalence of ADHD in the region increased significantly from 2.5% to 3.3% between 2000/01-2005/06 in line with the rest of Manitoba. It is significant however that in line with psychostimulant use; the region has the highest prevalence of ADHD outside the urban centres of Brandon and Winnipeg. AnxiolyticUse Anxiolytic medications are used to treat anxiety disorders and their symptoms which are amongst the most common psychological conditions in childhood. Some of the most commonly prescribed anxiolytics include benzodiazepines, zopiclone, chloral hydrate, and buspirone. The region’s rate of children (aged 0-19) with at least one anxiolytic prescription increased from 5.5/1,000 in 2000/01 to 6.8/1,000 in 2005/06. This is similar to the Manitoba average which increased from 5.0/1,000 to 6.1/1,000 in the same time period. The use of anxiolytic medications is more prevalent in girls and is considerably higher for older adolescents (15-19) than any other age group. AntipsychoticUse Antipsychotic medications have traditionally been used to treat children with psychoses or Tourette syndrome and, in some cases, to lessen severe self-injurious or aggressive behaviours which can be associated with autism and mental retardation. The region’s rate of children receiving antipsychotic prescriptions rose significantly from 1.6/1,000 to 3.7/1,000 from 2000/01 to 2005/06 in line with the rest of the province. The rates however were significantly lower than the provincial rates (3.6/1,000 – 2000/01 5.4/1,000 2005/06) in both time periods. Antipsychotic use is higher in adolescents (10-19) than any other age groups and no relationship was found between area level income and antipsychotic prescription use in rural areas. PG:242CHAPTER8:MENTALHEALTH Mortality SuicideRates Suicide rates in the region are similar to the provincial average and have increased slightly but not significantly from 1996-2000 to 2001-2005. Due to the low numbers the rates are extremely variable from year to year. Figure8.18SuicideRate/1,000Aged10+19962000and20012005(AgeandSex Adjusted) 19962000 20012005 MBAvg19962000 MBAvg20012005 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland NorMan Burntwood RuralSouth Mid North Manitoba 0.00 0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.40 SOURCE:MCHPRHAINDICATORSATLAS2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:243 FiveYearMortalityWithandWithoutCumulativeMentalIllness(CMI) The five year mortality rate for those residents with cumulative mental illness is 1.6 times that of residents without CMI. This is identical to both the provincial average and the average for the Rural South. There is no significant variance on a district level or between male and females. Figure8.195YearMortalityRate2001/20022005/06Aged19+WithandWithout CumulativeMentalIllness(AgeandSexAdjusted) withoutCMI withCMI MBAvgwithCMI MBAvgwithoutCMI SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0% 5% 10% 15% SOURCE:MCHPRHAINDICATORSATLAS2009 PG:244CHAPTER8:MENTALHEALTH ChapterHighlights Mental health clients continue to face stigmatization, and many also suffer from other chronic diseases. There has been increasing demand for community mental health services in recent years. Data show an increase in treatment prevalence for mental health conditions over time. Stress management continues to be a concern for community, partners and staff. Treatment prevalence for anxiety disorders and depression has increased over time. Antidepressant use by Assiniboine residents has increased significantly over time; however the proportion of clients who receive the recommended physician follow-up is low. Rates of antidepressant use among children are particularly high, as are prescriptions for psychostimulants to treat attention deficit/hyperactivity disorder. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:245 Chapter9:HomeBasedandLongTermCare HomeCare The Home Care program is a community-based program that provides home support to individuals, regardless of age, who require health services or assistance with activities of daily living. Home care works with individuals and provides assistance to help them stay in their homes for as long as is safely possible. A professional assessment of individual needs, existing supports and community resources determines eligibility for the Manitoba Home Care program and the type and amount of service a client may receive. The Manitoba Home Care program is responsible for ensuring the provision of reliable and safe assessed service in the home, educational setting, or workplace. To be eligible for the Manitoba Home Care program an individual must: be a Manitoba resident, registered with Manitoba Health; require health services or assistance with activities of daily living; require service to stay in their home for as long as possible; and require more assistance than that available from existing supports and community resources. Assessments (repeated at six monthly intervals) by home care case coordinators form the basis for decisions to provide home care, to change the type or amount of services delivered or to discharge the client from the program. The Assiniboine region has 18 case coordinators with 1,450 home care clients currently receiving services (April 2009). Staff indicated that gaps in continuity of care may occur when clients are discharged home from facilities without a service plan. This occurs more often when clients have been hospitalized outside the region. Other situations may arise when someone seeks attention at the emergency department after hours or on weekends and requires home care. In these cases, no one would be available to initiate a service plan. Remote clients may have limited access to home care services due to available resources. The Home Care program, like other programs and services, is affected by staffing challenges. Similar to other community health staff, home care staff feel that their practice could be improved by greater access to technology and administrative support. Home care staff mentioned a lack of therapy resources/equipment, stroke rehabilitation resources, resources for disabled children, speech therapy for feeding and swallowing concerns, and social workers. There appears to be a need for greater access to transitional care, respite beds, rehabilitation, and the Centre for Geriatric Psychiatry. The staff felt that building relationships among regions is important. PG:246CHAPTER9:HOMEBASEDANDLONGTERMCARE Utilization NewHomeCareCases The percentage of residents of any age in the region with a new home care case opened was significantly lower than both the provincial and Rural South averages (the lowest in the province) and remained unchanged from 1999/00-2000/01 to 2003/04-2004/05 at 1.01%. This compares to a provincial average of 1.38% for 2003/04-2005/06. In crude numbers this equates to some 944 new home care cases per year in the second period. There is no significant variation by district; however West 1 and East 1 have slightly higher rates, closer to the provincial average. Figure9.1NewHomeCareCases1999/002000/01and2003/042004/05(AgeandSex Adjusted) 1999/002000/01 2003/042004/05 MBAvg1999/002000/01 MBAvg2003/042004/05 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0.0% 0.5% 1.0% 1.5% 2.0% 2.5% SOURCE:MCHPRHAINDICATORSATLAS2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:247 OpenHomeCareCases The percentage of residents with an open home care case is also significantly below the provincial average and again the lowest in the province. The value has increased slightly from 2.25% in 1999/00-2000/01 to 2.36% in 2003/04-2004/05 but compares to provincial averages of 2.73% and 3.19% for the same time periods. The comparatively low rates of new and open home care cases were noted in the community health assessment of 2003/04 but have shown no significant increase sincethatreport. Figure9.2OpenHomeCareCases1999/002000/01and2003/042004/05(Ageand SexAdjusted) 1999/002000/01 2003/042004/05 MBAvg1999/002000/01 MBAvg2003/042004/05 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland Churchill NorMan Burntwood RuralSouth Mid North Manitoba 0% 1% 2% 3% 4% 5% 6% 7% SOURCE:MCHPRHAINDICATORSATLAS2009 PG:248CHAPTER9:HOMEBASEDANDLONGTERMCARE At a district level, only East 1 shows a higher percentage of open home care cases, closer to the provincial average. HomeCareClosingRates Home care closing rates (defined as the percentage of residents with a home care case closed during the year) are also significantly lower than the Manitoba average and have not increased significantly over time. The highest rates, closer to the Manitoba average, can be found in the East 1 district. Table9.1HomeCareClosingRates1999/002000/01and2003/042004/05(Ageand SexAdjusted) 1999/002000/01 2003/042004/05 ASEast2 1.05% 0.97% ASWest1 0.90% 1.06% ASNorth1 0.93% 1.07% ASWest2 0.93% 0.88% ASEast1 1.08% 1.20% ASNorth2 0.89% 0.97% Assiniboine 0.98% 1.04% RuralSouth 1.08% 1.10% Manitoba 1.29% 1.47% SOURCE:MCHPRHAINDICATORSATLAS2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:249 AverageLengthofHomeCareCases The average length of home care cases is very similar to the provincial average and has not changed markedly in recent years. The average length for males however is slightly longer than that for females, a pattern which is contrary to that seen in the rest of the province. The lowest values can be found in the North 2 and West 2 districts at 197 and 202 days respectively. Table9.2AverageLengthofHomeCareCases1999/002000/01and2003/042004/05 (AgeandSexAdjusted) 1999/002000/01 2003/042004/05 ASEast2 210 228 ASWest1 222 212 ASNorth1 221 227 ASWest2 242 202 ASEast1 204 231 ASNorth2 200 197 Assiniboine 231 230 RuralSouth 226 242 Manitoba 220 222 SOURCE:MCHPRHAINDICATORSATLAS2009 BenzodiazepinePrescribinginCommunityDwellingSeniors The use of benzodiazepines (a group of drugs used primarily in treating insomnia, anxiety, and agitation) in seniors is not generally recommended because they are at increased risk of both short term and long term adverse effects from the drug including cognitive impairment and behavioural disinhibition as well as physical dependence. The region has a relatively high rate of benzodiazepine prescribing with 22% of community dwelling seniors (aged 75+) who had at least two prescriptions or a greater than 30-day supply dispensed in 2005/06, a small increase from 21% in 2000/01 and higher than the Manitoba average of 19%. Rates are particularly high in the West 1 and East 1 districts, where over a quarter of the community dwelling seniors were prescribed benzodiazepines in 2005/06. PG:250CHAPTER9:HOMEBASEDANDLONGTERMCARE Figure9.3PrescribingofBenzodiazepinesinCommunityDwellingSeniors2000/01 and2005/06 2000/01 2005/06 MBAvg2000/01 MBAvg2005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland RuralSouth Mid Manitoba 0% 5% 10% 15% 20% 25% 30% SOURCE:MCHPRHAINDICATORSATLAS2009 SupportServicestoSeniors Support Services to Seniors offer community based-programs for seniors that support health and well being and provide support and assistance for seniors and individuals living with disabilities to maintain their independence in the community. Based on the needs of the community, a wide range of support services are available, such as congregate meals, meals on wheels, disease/disability/injury prevention, wellness promotion, fitness programs, volunteer opportunities, grocery shopping, escorts to appointments, transportation, friendly visiting, information and referral, foot care, personal emergency response systems (Emergency Response Information Kits), snow removal, and home maintenance. Support Services to Seniors community resource coordinators may also coordinate transportation options for seniors and the disabled in the communities. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:251 These programs function under various titles in different communities and are operated by local Community Resource Councils that receive funding through the regional health authorities. Frequently the funding is sufficient for only part-time positions. It was mentioned during the community engagement that it would benefit clients if Support Services to Seniors were available in the community for more hours during the week. In Assiniboine, there are 26 Community Resource Councils employing 34 community resource coordinators. In 2008/2009, the number of clients served by the Support Services to Seniors Boards within the ARHA was 11,914. It would be beneficial if more health care providers were aware of the services that are offered through these support service programs. Good communication between the health care system and support services are essential for optimizing outcomes. CongregateMealProgram The Congregate Meal programs offer older adults the opportunity to enjoy well-balanced affordable meals in a social setting, three to five days per week. In Assiniboine, there are 18 Congregate Meal programs which serve on average 326 meals per day, a total of 65,163 meals in 2008/2009. MealsonWheels The Meals on Wheels program provides facility prepared meals, which are delivered by volunteers to people of all ages in the community who are unable to prepare an adequate meal for themselves because of physical disabilities. The number of meals served per week varies depending on the community. Most facilities will prepare between 30 and 109 per week for residents of the region. As with many programs that require volunteers, it can be challenging to find sufficient volunteers to deliver meals. SupportiveHousing Supportive Housing provides access to 24-hour support and supervision within a group congregate setting for frail and/or cognitively impaired individuals who can no longer manage in the community within available resources but are not yet ready for personal care home (PCH) placement. The need for supportive housing was mentioned in almost every area of the region. There is concern about housing options for seniors from community members, staff, and partners. Some partners and staff have mentioned that at times seniors are staying in their homes too long because there is no alternative in the community other than a personal care home. There were concerns about the safety of these seniors. In other situations, it was said that seniors may enter a personal care home before they are ready because there are no alternatives but they are not comfortable remaining in their own homes. PG:252CHAPTER9:HOMEBASEDANDLONGTERMCARE SupportstoSeniorsinGroupLiving(SSGL) Support to Seniors in Group Living (SSGL) is housing with enhanced support services that support health promotion and independence with a goal of aging in place. The SSGL model targets individuals (primarily seniors) who do not require 24 hour support and supervision. Residents are assisted with Instrumental Activities of Daily Living (IADLs). These are life management skills which allow an individual to remain independent in the community e.g. shopping, telephone use, preparing meals, managing money, banking procedures, appointment scheduling, socialization, and recreational activities. The Assiniboine region is working in partnership with communities to establish supportive housing initiatives. Currently, there is a supportive housing and SSGL project in Neepawa. In Virden an SSGL project is currently in the planning stages. There are 120 Elderly Persons Housing (EPH) beds spread across the region offering supportive housing in the communities of Hamiota, Treherne, Rivers, Shoal Lake and Birtle. Respitecare Respite care is the provision of short-term, temporary relief to those who are caring for family members who might otherwise require permanent placement in a facility outside the home. The region’s respite program provides planned short-term breaks for families and other unpaid care givers either in the home or in facilities across the region. The number of respite days in facilities has gradually declined from 1,264 in 2005/06 to only 446 in 2008/09. AdultDayProgram There are 16 Adult Day programs throughout the region providing socialization and respite opportunities that assist clients in continuing to live safely and independently in the community. The number of program days offered has steadily climbed from 1,682 in 2005/06 to 1,730 in 2008/09. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:253 LongTermCare PersonalCareHomes The goal of long term care is to provide personal care for those individuals who are not able to remain in their own homes due to physical, social, or psychological challenges. The region has 28 personal care homes spread across the RHA with 878 beds delivering long term care to predominantly older residents with chronic illness or disability. Activities or Recreational Therapy services are provided in all personal care homes. Organized activities provide residents with opportunities for meaningful social interaction and allow them to remain active within a context that is appropriate for their needs and interests. Activities are planned so as to restore, support, or enhance social, physical, emotional, and spiritual well-being. The region has a relatively stable supply of personal care home beds, increasing slightly from 121/1,000 residents aged 75+ in 1999/00-2000/01 to 125/1,000 in 2004/05-2005/06. The vast majority of these beds are utilized by residents of the RHA (97% in 2004-20052005/2006) and indeed the same percentage of residents of the RHA that are admitted to a personal care home, do so within the region. Around 3.5% of all residents aged 75+ are admitted to a personal care home every year in the region which equates to just over 250 individuals. This is slightly higher than the provincial average of 3.0%. (These are crude values, age and sex adjusted values are slightly more disparate, but not significantly so.) This rate of admission means that in any given year approximately 13-15% of residents aged 75+ reside in one of the region’s personal care homes compared to 13% in Manitoba as a whole. PG:254CHAPTER9:HOMEBASEDANDLONGTERMCARE Figure9.4PersonalCareHomeBeds/1,000Residentsaged75+1999/20002000/2001 (00)and2004/20052005/2006(05) Provincial Federal SouthEastman00 SouthEastman05 Central00 Central05 Assiniboine00 Assiniboine05 Brandon00 Brandon05 Winnipeg00 Winnipeg05 Interlake00 Interlake05 NorthEastman00 NorthEastman05 Parkland00 Parkland05 NorMan00 NorMan05 Burntwood00 Burntwood05 RuralSouth00 RuralSouth05 Mid00 Mid05 North00 North05 Manitoba00 Manitoba05 0 25 50 75 100 125 150 175 200 225 SOURCE:MCHPRHAINDICATORSATLAS2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:255 LevelofCareonAdmission The level of care on admission to a personal care home is a measure of the relative needs of the individual when they are admitted. Level 1 is an individual that requires minimal support/supervision and the level of need increases, rising to Level 4, an individual that requires a much higher level of care. The current levels of care were established several decades ago. Due to the increasingly complex nature of long term care, such as behavioural issues and complex chronic care needs, the levels may not always provide an accurate picture of the actual care needs. The region has a very high rate of admitting residents with level one and level two (minimal or partial supervision required) care requirements, 61% compared to a provincial average of just 44%. This is particularly noticeable with female residents of the region where fully 71% of those admitted to a personal care home have a level one or two care requirement. This is inconsistent with the provincial trend towards reducing the need for institutionalization in favour of community based care and is possibly a result of the relatively low rates of residents receiving home care in the region. TherearetwopersonalcarehomesintheAssiniboineregionthatonlyadmitclients withLevel1andLevel2carerequirementswhichmaypartiallyexplainthehighrateof admissionsinthosecategories. PG:256CHAPTER9:HOMEBASEDANDLONGTERMCARE Figure9.5LevelofCareonAdmissiontoPCH,Residentsaged75+1999/2000 2000/2001(00)and2004/20052005/2006(05) Level1&2 Level3 Level4 SouthEastman00 SouthEastman05 Central00 Central05 Assiniboine00 Assiniboine05 67% 61% 28% 31% 6% 7% Brandon00 Brandon05 Winnipeg00 Winnipeg05 Interlake00 Interlake05 NorthEastman00 NorthEastman05 Parkland00 Parkland05 NorMan00 NorMan05 52% 44% South00 South05 40% 47% 8% 9% Mid00 Mid05 North00 North05 50% 44% Manitoba00 Manitoba05 0% 20% 39% 45% 40% 60% 11% 11% 80% 100% SOURCE:MCHPRHAINDICATORSATLAS2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:257 PersonalCareHomeWaitingTimes Wait time for admission to a personal care home (PCH) can be measured by the median wait time, which means the amount of time it took for half of all residents to be admitted after being assessed for PCH eligibility. For example, in 2005/06 half of Assiniboine residents waited less than 6 weeks from assessment to admission and half waited longer than 6 weeks. The region has amongst the shortest median wait time for admission to a personal care home in the province at just six weeks after assessment compared to 7.4 weeks for Manitoba as a whole. The wait time is considerably shorter for males at just 3.7 weeks, likely because they are generally admitted at a higher level of care and subsequently given preference on the waiting list to those with a lesser need. It should be noted that values shown are regional median wait times and that because clients are given a choice of personal care home, wait times for individual facilitiescanvaryconsiderably. Table9.3MedianWaitTime(weeks)fromAssessmenttoAdmission2004/2005 2005/2006 Male Female Overall SouthEastman 15.7 26.2 21.0 Central 12.0 13.6 13.1 Assiniboine 3.7 7.6 6.0 Brandon 9.0 10.9 10.1 Winnipeg 3.7 4.4 4.1 Interlake 10.0 10.4 10.2 NorthEastman 14.1 23.1 22.9 Parkland 7.2 8.9 7.7 NorMan 1.5 4.6 2.9 Burntwood 1.0 0.4 0.7 Manitoba 6.0 7.4 6.9 SOURCE:MCHPRHAINDICATORSATLAS2009 Some of the allied health professional services that personal care home residents may have difficulty accessing are; dental services, vision care, hearing services, foot care, support groups, addiction services, and mental health support. Staff indicated that it would be valuable to have social workers available to assist with transitions and to facilitate communication among staff, residents, and families. PG:258CHAPTER9:HOMEBASEDANDLONGTERMCARE MedianLengthofStay The median length of stay in Assiniboine personal care homes has dropped significantly from 1999/2000-2000/2001 to 2004/2005-2005/2006 at all levels of care, and other than Level 4 admissions, are lower than the provincial averages. In contrast to Manitoba and the Rural South, the median length of stay does not decline as the level of care on admission increases, but is actually longer for Level 4 admissions than for Level 3. Table9.4MedianLengthofStay(Years)byLevelofCareonAdmissiontoPCH, 1999/20002000/2001and2004/20052005/2006 All Level12 Level3 Level4 1999/2000 2000/2001 Assiniboine 2.35 2.83 1.68 2.39 RuralSouth 2.51 3.09 1.69 1.78 Manitoba 2.33 2.91 1.88 1.53 2004/2005 2005/2006 Assiniboine 1.98 2.25 1.29 1.60 RuralSouth 2.02 2.53 1.66 1.40 Manitoba 1.89 2.42 1.59 1.21 SOURCE:MCHPRHAINDICATORSATLAS2009 QualityofCare The Assiniboine region participates in the provincial Long Term Care Standards review process which involves regular visits and independent assessments by staff of Manitoba Health. HealthcareAssociatedInfections Healthcare associated infections are of particular concern in personal care homes where there are a large number of often frail and/or sick residents in close proximity. Particular care is given to restrict the spread of infection with regular hand washing and the use of alcohol rubs by staff working in the facility. A comprehensive reporting system is used to track infections in order to quickly identify and address any outbreaks. In the fiscal year 2008/2009, 1,209 healthcare associated infections were reported in the region’s personal care homes, the majority of which (43%) were urinary tract infections. This represents a modest decline from the 2007/2008 figure of 1,312. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:259 BenzodiazepinePrescribing The use of benzodiazepines (a group of drugs used primarily in treating, insomnia, anxiety, and agitation ) in seniors is not generally recommended because they are at increased risk of both short term and long term adverse effects from the drug including cognitive impairment and behavioural disinhibition as well as physical dependence. The region has the highest rate of benzodiazepine prescribing in the province with 44% of personal care home residents who had at least two prescriptions or a greater than 30day supply dispensed in 2005/06, an increase from 38% in 2000/01 and significantly higher than the Manitoba average of 33%. Figure9.6PrescribingofBenzodiazepinesinPersonalCareHomes2000/01and 2005/06 2000/01 2005/06 MBAvg2000/01 MBAvg2005/06 SouthEastman Central Assiniboine Brandon Winnipeg Interlake NorthEastman Parkland RuralSouth Mid Manitoba 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% SOURCE:MCHPRHAINDICATORSATLAS2009 PG:260CHAPTER9:HOMEBASEDANDLONGTERMCARE IncidentsofResidentAbusive/AggressiveBehaviour Aggressive or abusive behaviour by residents has seen a steady increase from 1.6/1,000 residents days in 2004/2005 (521 incidents) to 2.3 in 2008/2009 (719 incidents). This represents an increase of 44% over the five year period. ResidentFalls The number of resident falls reported in the region’s personal care homes has steadily increased from a rate of 5.9 falls per one thousand resident days in 2004/2005 to 9.2 in 2008/2009, an increase of 56%. This equates to 1,863 and 2,873 falls respectively. The region is developing a comprehensive program for falls prevention, assessment, and management beginning with long term care facilities in an attempt to address this issue. Figure9.7PersonalCareHomes–ResidentFallsper1,000ResidentDays2004/2005 2008/2009 PersonalCareHomeResidentFalls 10.0 9.0 9.2 8.9 8.4 8.0 7.6 7.0 6.0 5.9 5.0 4.0 3.0 2.0 1.0 0.0 2004/2005 2005/2006 2006/2007 2007/2008 2008/2009 SOURCE:ARHAINCIDENTREPORTING2009 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:261 MedicationVarianceIncidents A medication variance incident occurs when a resident does not receive the correct amount or type of medication within the time frame specified for that medication. The rate of medication variance incidents has steadily increased from 0.8/1,000 resident days in 2004/2005 to 1.7 in 2008/2009, an increase of 113% in the five year period. Figure9.8PersonalCareHomes–MedicationIncidentsper1,000ResidentDays 2004/20052008/2009 PersonalCareHomesMedicationIncidents 1.8 1.7 1.6 1.4 1.2 1.3 1.3 2006/2007 2007/2008 1.0 0.9 0.8 0.8 0.6 0.4 0.2 0.0 2004/2005 2005/2006 2008/2009 SOURCE:ARHAINCIDENTREPORTING2009 PG:262CHAPTER9:HOMEBASEDANDLONGTERMCARE PalliativeCare Palliative care is the active, compassionate care of the chronically and terminally ill, primarily directed towards improving the quality of life at a time when there is a not a cure. The emphasis on palliative care throughout the region is on control of pain and symptoms, and meeting the physical, emotional, spiritual, social, and cultural needs of the client and their family. It is multi-disciplinary in its approach, encompassing the client, family, caregivers, and the community in its scope and extends to include grief and bereavement. Palliative care services are provided in the home, in acute care, or long term facilities. Palliative care services include: Palliative Care Drug Access program including oxygen Pain and symptom Management Psychosocial support Bereavement support Camp Bridges (A grief and bereavement camp for 7 to 17 year olds) Education Professional Volunteer Table9.5PalliativeCareProgramEnrolments2006/20072008/2009 2006/07 2007/08 2008/09 ClientsEnrolled 338 357 369 CancerClients 218 225 248 OtherIllnesses 120 132 121 ClientsonDrugProgram 137 124 141 SOURCE:ARHAPALLIATIVECAREPROGRAM2009 Enrolment in the Palliative Care program has shown a steady increase over the past three years from 338 to 369 clients. The majority of this increase has been in clients diagnosed with cancer. In December 2002, Manitoba Health launched the Palliative Care Drug Access program, which provides eligible prescription drugs at no charge to palliative patients at the end stages of life. The utilization of this program has increased dramatically from just 32 residents approved in 2002/2003 to 141 in 2008/2009. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:263 ChapterHighlights There may be room to improve coordination of discharge planning for clients who may be eligible for home care services. Staffing shortages are also affecting the Home Care and Long Term Care programs. Community health staff could benefit from better access to technology and administrative support. Use of home care by Assiniboine residents continues to be lower than for other residents of Manitoba. There are strong supports for seniors and disabled residents in many communities. Declining numbers of volunteers may be affecting the ability to deliver some of these services such as Meals on Wheels, etc. Community, partners, and staff identified the need for more housing options that support seniors in our communities. These supports may help to prevent premature admissions to personal care homes. There have been increases in the number of falls among PCH residents and in the incidence of aggressive or abusive behaviour by PCH residents. The number of Assiniboine residents enrolled in the Palliative Care program has grown steadily in the last three years, mainly due to increases in cancer diagnoses. PG:264CHAPTER9:HOMEBASEDANDLONGTERMCARE ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:265 Chapter10:HealthAuthorityCharacteristics Expenditure The majority of RHA expenditure is in long-term and acute care (66.2%) and the distribution has changed little from 2008/2009. Expenditure has increased from 152 million in 2008/2009 to over 161 million in 2009/2010. Figure10.1Expenditurebyarea2008/2009FiscalYear UndistributedCosts10.1% MentalHealth1.2% EMS3.9% AcuteCare32.7% PublicHealth4.0% PrimaryCare6.8% HomeCare7.8% LongTermCare33.5% SOURCE:ARHACONSOLIDATEDSTATEMENTOFOPERATIONS2009 Notes: UndistributedcostsincludeRHAcosts,Amortizationofcapitalassets,ancillarycostsandpre retirementcosts. TherapyservicesareincludedinAcute,LongTermCareandHomeCare PrimaryCareincludesCommunityHealthclinicsandmedicalremuneration CommunitybasedadministrationisincludedinPublicHealth,HomeCareandMentalHealth PG:266CHAPTER10:HEALTHAUTHORITYCHARACTERISTICS Communication Communication is a priority for the Assiniboine region. Given the large geography, timely communication can be a formidable task. Over the years, however, a number of successful communication approaches have been developed. Public communication is achieved through several modes: public website, public newspaper, press releases, newspaper articles and advertisements, posters, mail drops, and regular in person meetings between the Board, Executive Management Committee, and community stakeholders. When there are specific issues in a community, leaders are usually contacted by telephone and in person meetings are held. Board meeting minutes are posted on the Assiniboine RHA website. Each year the Board holds an Annual General Meeting that is open to the public. The Assiniboine Health Advisory Council, which is discussed later in this chapter, acts as a communication venue to Assiniboine communities. It is important for the public to know about the programs and services we offer. The Assiniboine RHA website provides a listing of programs and services, along with contact information. Many programs have brochures and handbooks which provide information about services provided, contact information, and client rights and responsibilities. With the increasing number of immigrants joining our communities, the Assiniboine region is working with the Winnipeg Regional Health Authority to acquire translation services. There is a volunteer translator program, which includes volunteers from the Aboriginal community. As mentioned in Chapter 2, the region has a French Language Services plan and a translation agreement with the Conseil Communauté en Santé du Manitoba. Clients may access the provincial Health Links – Info Santé telephone resource in 110 languages. See Chapter 5 for more details about this service. Communication with staff is also a regional priority. This is accomplished through regular bulletins called FYI, Staff Matters newsletters, faxes, an Urgent Communication link on eligible RHA computers, and twice annual staff meetings. The Assiniboine Provider Advisory Council, described later in this chapter, also provides a link to staff. Regional policies and procedures are available to staff on the regional intranet. There is a link on the regional website specifically for staff. The Disaster and Emergency Response Plan and Pandemic plan are posted on the website. The Executive Management Committee schedules meetings with staff while they are visiting communities for the stakeholder meetings. During the H1N1 outbreak, several teleconferences were set up to allow all staff and physicians to obtain information and ask questions about the situation and care guidelines. These teleconferences were well received by staff. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:267 Leadership Since the last comprehensive community health assessment (CHA) in 2004, there have been several new programs developed in an effort to better meet the needs of the population. While the decision to establish the programs may have been influenced by results from the CHA, there are many factors which determine whether or not programs are developed or revised, such as feasibility, resources required, readiness of staff, and opportunity costs. Community health assessment is an ongoing process, with new information becoming available all the time. The Board and Executive Management Committee review new and updated information annually through the Strategic Planning process. The Planning and Evaluation Team also work with managers on an ongoing basis to provide the necessary information to support program decisions. The results from previous community health assessments on ongoing activities may have contributed to the implementation or revision of the following: Establishment of mobile Women’s Wellness Clinics Establishment of a Chronic Disease Prevention and Management Committee Development of the Acute Coronary Syndrome Care Map Establishment of the Roaring Adventures of Puff Asthma management pilot Development of the Aboriginal Specific Health Strategy Establishment of injury prevention priorities (falls prevention, motor vehicle safety, bike safety) Development of targeted mental health promotion activities Involvement in chronic disease risk factor surveillance Establishment of the Rivers Rehabilitation program SystemCapacity A significant way of assessing the health of the population is through research. Thus far, the region has been a partner in conducting research relative to population health. Through the Manitoba Centre for Health Policy project, The Need to Know Team, two representatives from the region participate in collaborative provincial activities that contribute to the creation of new knowledge, training in research utilization, and communication of findings. This partnership is critical to evidence-informed decisionmaking at the regional level. The region partnered with CancerCare Manitoba and other regional health authorities to conduct the Youth Health Survey, as described in Chapter 3 of this report. A grant from the Public Health Agency of Canada provided the opportunity to partner with CancerCare Manitoba again to do the Adult Health Survey, which is also described in Chapter 3. PG:268CHAPTER10:HEALTHAUTHORITYCHARACTERISTICS Currently we do not have the capacity to conduct rigorous research independently, but the region appreciates opportunities to partner with researchers to conduct studies that will contribute to the existing knowledge base. In recent years, the region has participated in several studies, including West Nile Virus prevalence, immunization data systems, and a palliative care study. ClientSatisfaction Providing quality care is very important in the Assiniboine region. If a client or family have concerns about the care provided in the region, there is a process for them to express their concerns. One member of the Regional Leadership Team is designated to respond to the initial concern in writing within a specified time frame. The concern is then referred to the appropriate manager in order to have the issue followed up and addressed. It is expected that the result of the investigation is communicated back within a reasonable time frame to the person who reported the concern. Most programs and services conduct regular assessments of client satisfaction in order to identify ways to improve care and service. When clients were asked to rate the overall quality of the programs and services they used in the region, an overwhelming majority rated them either good or excellent. Table10.1ClientSatisfactionwithOverallQuality AcuteCare CancerCare Diagnostics HomeCare LongTermCare Maternity&NewbornCare(PublicHealth) Maternity&NewbornCare(ObstetricalSites) MentalHealth Palliative&HospiceCare PrimaryCare Rehabilitation Women’sWellness TimePeriod January2007June2009 October2006 April2006 May2007 January2007January2009 July2007June2009 January2007December2008 January2007December2008 March2008 November2007June2009 January2007December2008 January2008June2009 Proportion RatingQuality asGoodor Excellent 95% 95% 98% 97% 94% 95% 97% 94% 96% 99% 100% 98% SOURCE:ARHAQUALITYANDRISKASSESSMENT2010 ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:269 HumanResources Human Resource Services is a regional service that provides support to the Assiniboine Regional Health Authority operations, programs, and services in the area of Human Resource Management. Human Resource Services programs include: Recruitment & Retention Labour Relations Occupational Health & Safety (Ability and Attendance Assistance) Quadrant HR System Compensation & Benefits As mentioned throughout the previous chapters, maintaining adequate human resources is one of the most significant challenges facing the Assiniboine region. Recruitment of almost every type of health care provider is ongoing. Many of the staff are approaching retirement age. This is concerning for future operations in many programs. Community members provided suggestions for increasing training opportunities for local students in the health professions. Recruitment and retention of staff is a priority for the Human Resources department. The Assiniboine Regional Health Authority’s recruitment and retention goal is to ensure that consistent practices are in place to recruit and select qualified individuals, thereby ensuring adequate numbers of staff and volunteers. The region participates in many recruitment initiatives to improve the recruitment of health professionals to ensure needs are met. Some of these initiatives include: Attendance at post-secondary educational career fairs Attendance at high school career fairs Healthcare career presentations to high school students & post-secondary educational institutions Student practicum / Job shadowing / Take your Kids to Work opportunities available Advertising – website focus, newspaper/magazine ads Summer student positions available Partnerships with communities Grad Registered Nurse Mentorship program Aboriginal Workforce Strategy Promoting Nurse Recruitment & Retention Fund grants offered through Manitoba Health. Promote community/health auxiliary/regional union scholarships and bursaries. Rural Health Care Aide program delivery by post-secondary education institutions. Rural Licensed Practical Nurse program delivered by Assiniboine Community College based on demand. PG:270CHAPTER10:HEALTHAUTHORITYCHARACTERISTICS There is a separate Physician Recruitment Initiative in the region that includes linkages with medical schools, participation in career fairs, return of service agreements, an online recruitment component, and assistance with licensing and immigration processes for International Medical Graduates. Some of the retention initiatives that occur in the Region for employees include: Regional Orientation sessions Regional Educational Advance program Provide education opportunities for staff ARHA Continuing Education Nursing Fund Performance Appraisal program Comprehensive Recognition program Annual celebration of service milestones (10+ years and recognition of retirements) Team Assiniboine Distinguished Achievement Awards Team Assiniboine Gratitude Cards Team Assiniboine Profile Staff Profiles Team Assiniboine Spirit Week Employee challenge to improve the organization Workplace Wellness Quality of Worklife Survey Ability Assistance program In an effort to gain a better understanding of the reasons that staff leave the region, exit interviews are offered to staff and physicians who resign or retire. A process for regular performance appraisals has been established for all employees of the region. The performance appraisal process offers an opportunity to collaboratively identify, recognize, and acknowledge performance. This may range from commending excellent performance to identifying opportunities for improvement. Orientation Regional Orientation is a mandatory session held 5 times throughout the year for new employees in the Assiniboine Regional Health Authority. This two day information session provides all new employees with an understanding of the health region and the many processes within it. All new employees within the Assiniboine Regional Health Authority also participate in completing a Site Orientation Checklist at their worksite. This process assists and enables new employees to transition more effectively and easily into their positions. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:271 Existing staff provide new employees support, guidance, and coaching which aids in becoming a successful satisfied employee of the ARHA. This allows new employees to feel supported both in their skill development and in their workplace development. Some of the benefits available to employees of the Assiniboine region include: Employee Assistance Plan Health Care Employees Benefits Plan Health Care Employees Pension Plan Salary Protection including vacation/sick/family sick/compassionate (bereavement) Leave Education Processes Recognition program OccupationalHealthandSafety The ARHA Occupational Health and Safety program is designed to assist in the prevention of injury and positive health for staff as well as clients. The program consists of the site and program Workplace Safety and Health committees, Immunization program for staff, and all Workplace Safety and Health programs and policies. The ARHA Occupational Health and Safety program provides resources and direction to all ARHA facilities and programs to develop a culture of safety for all staff, clients, and visitors. Fluimmunizations Influenza immunization is strongly encouraged among regional staff in order to protect them and their clients from serious illness. Immunizations are offered through site staff immunization nurses who have received training in providing immunizations. The regional staff immunization rate has remained relatively consistent at just over 40%. Table10.2StaffInfluenzaImmunization20042008 2004 2005 2006 2007 2008 PercentofallARHAstaff immunized 41% 43% 49% 42% 43% SOURCE:ARHAIMMUNIZATIONPROGRAM2009 PG:272CHAPTER10:HEALTHAUTHORITYCHARACTERISTICS Worklife Through the Accreditation process, staff were given the opportunity in 2008 to complete a survey assessing their perceived worklife. There were 1,232 staff who responded, for a response rate of 41%. There was a great deal of variation in responses among sites. Of the staff who responded, 49% either agreed or agreed strongly that overall they are satisfied with the organization. Only 32% of staff were satisfied with communication in the organization, however 48% were satisfied with communication in their work area. The majority (71%) of staff were clear about what is expected of them to do their job. When asked if they were satisfied with the amount of control they have over job activities, 53% agreed or strongly agreed. When asked how satisfied they were with their job, 86% or Assiniboine staff were either very satisfied or somewhat satisfied. Since then the Provider Advisory Council has developed a process to assess quality of worklife for Assiniboine employees. This process, which consists of conversations at staff meetings in every department based on a standardized set of questions, was meant to gain a better understanding of the worklife challenges in the region. Results from this recent initiative were not available at the time of writing. Continuing education opportunities can promote retention of staff. Fifty-two percent of staff felt that the organization supports their learning and development. StaffEducation Access to continuing education is essential for health care providers. There are many continuing education opportunities for staff, particularly for nurses, who provide care around the clock. Courses and educational programs offered in the Assiniboine region include: Advanced Cardiac Life Support, Neonatal Resuscitation Provider, Trauma Nursing Core Course, Cardiac Rhythm Review, Food Safe, Knowledge and Skills Development Training for untrained health care aides, Feeding & Swallowing Difficulties Management program, Nonviolent Crisis Intervention Training, Home Care Skills Lab, PIECES dementia care training, Basic Cardiac Life Support, ASIST Suicide Prevention, Mental Health First Aid, Lifts & Transfers, Client Transfer Assessment, Casual Immunization Orientation, Palliative Care Volunteer training program, Body Mechanics, Respectful Workplace, and IT skills. Staff appreciate the opportunity to access educational in-services on site, such as the Code Blue and Emergency Deliveries training sessions. Annual training is provided to long term care staff through an education series entitled Embracing The Challenge. This education is offered at the local sites to allow as many staff as possible to attend. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:273 Employees also complete self-learning packages that are relevant to their work, such as Confidentiality, WHMIS, Regional Disaster & Emergency Response Plan, Client Abuse, and Resident Bill of Rights. An eLearning initiative has allowed nursing and designated staff to access continuing education resources and opportunities via computer. Resources available for designated staff include learning modules on: wound care, infusion pumps, central venous access device (CVAD) care, blood administration and breastfeeding, as well as links to many other educational resources. The eLearning resource will eventually allow all staff to be able to complete required self-learning packages online and automatically record successful completion in their employee record. The EMS program was the first to use an eLearning format. Courses and continuing staff education has been successfully delivered to Assiniboine EMS staff for several years. Volunteers There are many volunteers who assist with the daily activities of the region. Volunteers assist with feeding, activities, and entertainment for personal care home residents, delivering Meals on Wheels and congregate meals, assisting with immunization clinics, support for palliative care and lab delivery, Support Services to Seniors, and many others. The Assiniboine region recognizes volunteers on an annual basis at the community level. PatientSafety There is increasing attention being paid to patient safety and quality of care provided. In recent years, safety advocates have attempted to quantify risks to client safety. Through the Accreditation Worklife survey, staff were asked if working conditions in their area contribute to patient safety. Of the staff who responded, 68% either agreed or strongly agreed. There are a number of patient or client safety initiatives in the Assiniboine region. Through participation in the Accreditation process, the organization is working towards implementing many Required Organizational Practices, such as medication reconciliation, falls prevention, and infusion pump training. The results of patient safety initiatives are reported to the Board on a regular basis. ClientCentredServices The Assiniboine region engages a number of groups to participate in planning programs and services. The Assiniboine Health Advisory Council (AHAC) is a group of interested community members who provide advice to the Board of Directors and Executive Management Committee. This group meets three to four times per year with the Board of Directors, Executive Management Committee, and Provider Advisory Council. PG:274CHAPTER10:HEALTHAUTHORITYCHARACTERISTICS The Provider Advisory Council is a multi-disciplinary group of interested staff who provide advice to the Board of Director and Executive Management Committee. While this group participates in the AHAC Board engagement meeting, they also meet independently to discuss areas of staff interest in the region. Most recently, the Provider Advisory Council designed a process to obtain employee feedback on working conditions and employee satisfaction. The Provider Advisory Council reviews the feedback with Human Resources and makes recommendations to improve the worklife of employees. The Medical Advisory Council is an active group of physicians who provide feedback to the Board of Directors and Executive Management Committee in areas of physician privileges, medical systems input, and act as liaisons with various provincial committees. The Medical Advisory Council has also agreed to fulfill several roles that would normally be assumed by a Vice President of Medical Services, a testament to their commitment to quality care in the region. The Regional Planning Committee advises the Health Promotion Team regarding programs such as the Chronic Disease Prevention Initiative. This initiative has been developed collaboratively with the members of the committee. The committee is closely involved with the planning and decisions surrounding the initiative. There are numerous other interagency partnerships that exist for the purpose of sharing information and mutual planning, such as the Police Agencies meeting, Suicide Prevention Intervention Network, Body Image Network, and Westman Healthy Lifestyle Coalition. ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:275 ChapterHighlights The Assiniboine region expends tremendous effort in communication and recruitment and retention of staff. Clients who respond to satisfaction questionnaires are generally quite satisfied with the overall care provided. Staff education is a priority in the region. The development of an eLearning system allows greater access to continuing education for Assiniboine staff. Volunteers provide a significant contribution to care and quality of life for clients in the regions. PG:276CHAPTER10:HEALTHAUTHORITYCHARACTERISTICS ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:277 ReferenceList Assiniboine Regional Health Authority, 2008. Assiniboine RHA Adult Health Survey (Unpublished document). Assiniboine Regional Health Authority, 2007. Assiniboine RHA Youth Health Survey (Unpublished document). Brasfield, C., 2001. Residential School Syndrome. .BC Medical Journal, Vol. 43, No. 2, March 2001, page(s) 78-81), Available online at: http://www.bcmj.org/residential-schoolsyndrome. Brownell, M., De Coster, C., Penfold, R., Derksen, S., Au, W., Schultz, J. & Dahl, M., 2008. Manitoba Child Health Atlas Update, Winnipeg: Manitoba Centre for Health Policy. Canadian Association of Occupational Therapists, 2010. Available online at: http://www.caot.ca/. Canadian Institute for Health Information, 2009. Health Indicators 2009, Ottawa. Canadian Physiotherapy Association, 2010. Available online at: http://thesehands.ca/index.php CancerCare Manitoba, 2009. Health Information Management Branch, 2009. Updated Regional Profiles. Winnipeg: Manitoba Health. (Unpublished document). CancerCare Manitoba, 2010. Regional Community Cancer Program Statistics. Winnipeg: Cancer Care Manitoba (Unpublished). Donner, L., Isfeld, H., Haworth-Brockman, M. & Forsey, C., 2008. A Profile of Women’s Health in Manitoba. Winnipeg: Prairie Women’s Health Centre of Excellence. First Nations Regional Longitudinal Health Survey, 2005. Ottawa: Available online at: http://www.rhs-ers.ca/english/pdf/rhs2002-03reports/rhs2002-03-technical_report.pdf. Fransoo, R., Martens, P., The Need to Know Team, Burland, E., Prior, H, Burchill, C., Chateau, D, & Walld, R., 2005. Sex Differences in Health Status, Health Care Use and Quality of Care: A Population-Based Analysis for Manitoba’s Regional Health Authorities. Winnipeg: Manitoba Centre for Health Policy. Fransoo, R., Martens, P, Burland, E., The Need to Know Team, Prior, H., & Burchill, C., 2009. Manitoba RHA Indicators Atlas 2009. Winnipeg: Manitoba Centre for Health Policy. PG:278REFERENCELIST Health Information Management Branch, 2008. Regional Profiles. Winnipeg: Manitoba Health. (Unpublished document). Health Information Management Branch, 2009. Updated Regional Profiles. Winnipeg: Manitoba Health. (Unpublished document). Health Links – Info Santé, 2009. Program Statistics, Winnipeg. (Unpublished document). Healthy Child Manitoba, 2008. EDI Reports 2005-2007 (Unpublished document). Healthy Child Manitoba, 2009. Families First Program Statistics. Winnipeg. (Unpublished). Manitoba Bureau of Statistics, 2008. In Health Information Management Regional Profiles (Unpublished document). Manitoba Health CDC, 20008. In Health Information Management Regional Profiles (Unpublished document). Manitoba Telehealth, 2009. Manitoba Telehealth Program Statistics. Winnipeg. (Unpublished document). Martens, P., Fransoo, R., McKeen, N., The Need to Know Team, Burland, E., Jebmani, L., Burchill, C., De Coster, C., Ekuma, O., Prior, H., Chateau, D., Robinson, R. & Metge, C., 2004. Patterns of Regional Mental Illness Disorder Diagnoses and Service Use in Manitoba: A Population-Based Study. Winnipeg: Manitoba Centre for Health Policy. Schnarch, B., 2004. Ownership, Control, Access and Possession (OCAP) or SelfDetermination as Applied to Research. Ottawa: National Aboriginal Health Organization. Available online at: http://www.research.utoronto.ca/ethics/pdf/human/nonspecific/OCAP%20principles.pdf Statistics Canada, 2008. Census Data in Health Information Management Regional Profiles (Unpublished document). Vital Statistics, 2009. In Health Information Management Branch, 2009. Updated Regional Profiles. Winnipeg: Manitoba Health. (Unpublished document). ASSINIBOINERHACOMMUNITYHEALTHASSESSMENT2009/2010 PG:279 Appendices Appendix1 The population of the Assiniboine Regional Health Authority as of June 1st 2008 by five year age groups, gender, and municipality of residence. Appendix2 The Assiniboine Youth Health Survey, based upon a school survey developed by the Interlake Regional Health Authority Appendix3 A list of the community engagement meetings and other engagement activities conducted as part of the community health assessment process. Appendix4 The Assiniboine Staff Survey utilised to gather opinions from the staff of the Assiniboine Regional Health Authority. Appendix5 A list of Manitoba’s Community Health Assessment Indicators used in this report and the page numbers on which they can be found. PG: 280 APPENDIX 1 ARHA POPULATION 2008 ARHAPOPULATIONBYAGEGROUPANDDISTRICTJUNE1ST2008 AGE 04 59 1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7074 75+ Total NORTH1 F M T 365 374 739 361 382 743 436 440 876 444 500 944 328 416 744 289 331 620 306 293 599 329 306 635 377 382 759 439 491 930 459 499 958 381 404 785 352 360 712 300 305 605 247 230 477 810 573 1383 6223 6286 12509 NORTH2 F M T 232 245 477 261 253 514 281 283 564 340 350 690 250 282 532 229 220 449 204 243 447 244 259 503 302 291 593 393 408 801 366 413 779 377 333 710 322 357 679 237 247 484 226 181 407 537 405 942 4801 4770 9571 F M T 303 304 607 299 330 629 319 351 670 324 379 703 303 349 652 268 287 555 290 271 561 301 276 577 299 300 599 378 362 740 402 392 794 375 357 732 270 330 600 261 241 502 221 200 421 631 415 1046 5244 5144 10388 F M T 305 368 673 318 351 669 390 415 805 451 490 941 368 391 759 274 317 591 298 285 583 337 344 681 385 377 762 454 441 895 448 492 940 429 470 899 393 389 782 329 344 673 268 261 529 771 509 1280 6218 6244 12462 F M T 249 278 527 247 273 520 276 300 576 318 332 650 241 287 528 224 237 461 240 221 461 227 203 430 270 245 515 350 322 672 360 355 715 291 309 600 262 273 535 228 208 436 209 189 398 600 420 1020 4592 4452 9044 F M T 375 405 780 373 391 764 465 480 945 517 530 1047 458 453 911 353 362 715 333 357 690 392 361 753 443 425 868 497 526 1023 517 544 1061 433 430 863 413 405 818 346 320 666 260 245 505 849 587 1436 7024 6821 13845 F M T 1829 1974 3803 1859 1980 3839 2167 2269 4436 2394 2581 4975 1948 2178 4126 1637 1754 3391 1671 1670 3341 1830 1749 3579 2076 2020 4096 2511 2550 5061 2552 2695 5247 2286 2303 4589 2012 2114 4126 1701 1665 3366 1431 1306 2737 4198 2909 7107 34102 33717 67819 EAST1 EAST2 WEST1 WEST2 ARHA SOURCE:MANITOBAHEALTHPOPULATIONREPORTS2009 PG: 281 APPENDIX 1 ARHA POPULATION 2008 DistrictNorth1 Age 04 ArchieRM F 12 M 11 BinscarthVillage F 15 M 13 BirdtailSiouxFN F 28 M 17 BirtleRM F 13 M 13 BirtleTown F 12 M 21 BoultonRM F 0 M 3 ElliceRM F 2 M 3 GamblersFN F 0 M 0 HamiotaRM F 4 M 6 HamiotaVillage F 32 M 19 MiniotaRM F 20 M 22 RossburnRM F 26 M 37 RossburnTown F 14 M 27 RussellRM F 2 M 1 RussellTown F 56 M 55 ShellmouthRM F 18 M 13 ShoalLakeRM F 7 M 7 ShoalLakeTown F 12 M 19 SilverCreekRM F 11 M 7 StLazareVillage F 14 M 15 WaywayseecappoFN F 67 M 65 59 1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7074 75+ Total 3 6 5 12 13 10 12 18 4 8 6 8 7 8 8 7 14 14 6 17 15 14 13 13 8 13 6 11 9 6 141 176 14 15 17 33 22 13 8 16 14 20 8 11 18 8 13 14 23 26 20 23 17 16 11 12 17 14 13 11 39 25 269 270 14 15 12 8 13 17 14 4 12 15 8 3 8 8 5 5 3 7 10 7 3 4 1 2 2 4 1 1 3 4 137 121 21 20 14 17 25 24 20 17 8 7 25 17 9 20 16 17 23 27 35 32 20 34 22 25 16 11 14 16 28 26 309 323 14 22 18 24 22 26 10 20 18 20 21 16 20 23 22 19 27 24 30 26 25 26 22 24 16 19 17 14 80 45 374 369 3 5 7 10 6 7 8 15 1 3 1 1 3 4 8 9 9 6 11 15 7 9 6 7 8 5 3 8 6 10 87 117 11 6 18 15 16 25 11 18 1 11 6 4 9 7 13 9 19 16 13 23 9 11 5 10 4 6 6 9 14 15 157 188 2 0 0 1 3 3 0 1 1 0 1 0 0 1 1 2 1 2 1 2 0 0 0 0 0 1 1 0 0 1 11 14 7 11 13 9 14 15 6 13 8 9 6 5 7 10 13 13 10 10 22 17 12 18 17 17 13 13 9 9 9 18 170 193 22 29 28 31 29 32 35 19 18 29 34 13 22 24 33 24 30 40 36 36 24 27 28 19 25 21 18 16 98 60 512 439 28 18 41 38 34 53 27 41 23 31 17 19 25 25 23 24 36 43 43 34 26 34 23 31 23 22 14 14 55 41 458 490 14 27 21 22 25 17 25 23 16 18 17 18 8 25 10 16 14 9 18 29 28 21 23 26 11 20 11 9 8 10 275 327 17 25 14 18 13 28 9 14 11 12 16 15 21 11 21 14 24 23 19 25 13 22 18 13 28 22 25 21 74 42 337 332 2 5 11 8 13 21 11 12 4 8 6 8 4 3 12 8 12 17 18 27 14 14 9 13 9 6 12 6 15 16 154 173 40 55 64 42 54 71 38 50 56 51 50 51 59 47 61 68 59 79 64 61 49 39 53 38 41 41 35 26 156 109 935 883 29 16 19 14 24 15 13 18 13 14 20 17 21 19 16 21 27 32 28 28 24 22 22 34 16 17 10 17 35 25 335 322 8 15 12 16 13 17 14 19 9 13 5 11 11 7 12 19 28 24 26 27 19 25 16 17 15 19 15 10 42 33 252 279 13 15 22 23 21 23 13 15 17 12 17 17 17 19 26 24 18 31 18 20 28 24 28 21 23 16 16 14 99 56 388 349 12 10 13 16 18 21 19 22 7 15 9 18 11 10 21 19 21 21 17 21 22 18 10 19 11 10 6 12 24 16 232 255 11 11 24 16 12 13 8 9 13 8 6 8 13 7 11 18 16 19 6 13 6 9 8 4 6 9 8 2 13 10 175 171 76 56 63 67 54 49 27 52 35 27 27 33 36 20 32 32 25 21 18 16 20 17 17 15 8 16 7 4 3 5 515 495 DistrictNorth1Totals F 365 361 M 374 382 436 440 444 500 328 416 289 331 306 293 329 306 377 382 439 491 459 499 381 404 352 360 300 305 247 230 810 573 6223 6286 PG: 282 APPENDIX 1 ARHA POPULATION 2008 DistrictNorth2 Age 04 BlanshardRM F 12 M 12 ClanwilliamRM F 5 M 1 EricksonTown F 22 M 15 HarrisonRM F 8 M 6 KeeseekooweninFN F 15 M 11 MinnedosaTown F 87 M 94 MintoRM F 2 M 3 OdanahRM F 6 M 11 ParkRMMarquette F 19 M 13 RapidCityTown F 26 M 34 RollingRiverFN F 13 M 13 SaskatchewanRM F 3 M 3 StrathclairRM F 14 M 29 59 1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7074 75+ Total 13 11 15 21 32 33 10 23 13 7 7 9 13 14 20 18 26 32 24 29 20 18 17 15 5 11 8 8 33 22 268 283 11 2 2 4 8 6 10 4 5 4 3 8 7 2 4 9 14 15 14 13 12 13 11 18 11 11 9 11 15 21 141 142 33 13 19 19 35 32 14 21 24 18 18 20 20 19 31 17 23 18 21 25 31 24 20 27 25 24 23 15 49 31 408 338 13 7 15 16 28 20 12 22 10 11 8 8 14 15 22 24 28 36 37 34 38 25 33 47 31 28 25 22 65 54 387 375 9 15 12 10 8 8 13 7 6 10 6 5 8 7 5 5 9 12 8 6 6 3 1 4 2 3 5 1 2 2 115 109 90 103 108 94 104 116 94 76 75 85 74 81 88 88 101 113 135 121 110 131 114 94 93 95 71 66 65 52 221 132 1630 1541 4 3 8 10 8 11 5 7 5 8 7 10 4 6 5 5 15 17 16 18 13 14 11 16 7 7 7 8 13 10 130 153 10 10 9 9 10 10 7 14 10 14 11 11 4 11 10 10 14 8 13 12 9 15 14 6 16 16 7 10 13 16 163 183 14 16 23 21 24 21 13 26 22 15 23 24 19 29 30 32 39 34 35 40 53 54 57 51 29 35 26 24 28 44 454 479 21 22 16 22 22 31 14 21 21 21 21 26 23 25 28 18 23 36 22 28 18 14 8 17 7 8 10 7 21 10 301 340 10 8 14 13 10 14 14 12 7 8 4 5 10 9 14 9 8 15 4 7 3 3 1 2 3 1 6 3 3 1 124 123 7 5 10 13 17 20 9 20 9 6 2 7 8 7 8 7 19 23 27 24 18 19 27 19 10 18 10 5 17 18 201 214 26 38 30 31 34 28 35 29 22 13 20 29 26 27 24 24 40 41 35 46 42 37 29 40 20 19 25 15 57 44 479 490 DistrictNorth2Totals F 232 261 245 253 M 281 283 340 350 250 282 229 220 204 243 244 259 302 291 393 408 366 413 377 333 322 357 237 247 226 181 537 405 4801 4770 PG: 283 APPENDIX 1 ARHA POPULATION 2008 DistrictEast1 59 1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7074 75+ Total 73 83 60 78 69 62 47 42 52 46 84 64 76 63 66 57 67 79 58 57 66 53 52 52 50 40 32 28 134 75 1053 946 20 22 22 22 11 8 14 10 10 13 17 14 16 22 5 17 11 7 23 21 20 23 20 20 11 17 9 11 25 17 254 265 9 7 11 4 17 17 14 18 11 20 4 13 7 8 13 13 31 21 21 27 24 17 14 24 16 19 16 12 20 23 237 249 12 27 14 14 24 19 18 40 15 20 10 10 16 15 13 13 26 21 32 32 24 34 19 26 19 29 14 16 25 25 294 358 105 99 108 119 102 126 114 115 111 104 117 95 105 100 108 107 139 113 138 135 144 121 97 120 89 76 96 69 342 183 2013 1790 31 41 50 53 44 61 44 60 26 35 28 38 37 32 37 38 61 62 70 61 50 57 27 42 29 21 22 23 40 43 627 696 49 51 54 61 57 86 52 64 43 49 30 37 44 36 57 55 43 59 60 59 47 52 41 46 47 39 32 41 45 49 766 840 DistrictEast1Totals F 303 299 M 304 330 319 351 324 379 303 349 268 287 290 271 301 276 299 300 378 362 402 392 375 357 270 330 261 241 221 200 631 415 5244 5144 Age 04 CarberryTown F 67 M 67 GlenellaRM F 20 M 21 LangfordRM F 9 M 6 LansdowneRM F 13 M 17 NeepawaTown F 98 M 108 NorthCypressRM F 31 M 29 RosedaleRM F 65 M 56 PG: 284 APPENDIX 1 ARHA POPULATION 2008 DistrictEast2 Age 04 ArgyleRM F 23 M 21 CartwrightVillage F 19 M 20 GlenboroVillage F 30 M 28 KillarneyTown F 57 M 67 OaklandRM F 18 M 22 RiversideRM F 16 M 28 RoblinRM F 22 M 27 SouthCypressRM F 8 M 8 SouthNorfolkRM F 16 M 26 StrathconaRM F 7 M 6 TreherneVillage F 14 M 19 TurtleMountainRM F 18 M 28 VictoriaRM F 38 M 39 WawanesaVillage F 19 M 29 59 1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7074 75+ Total 29 35 41 42 37 33 27 40 16 22 21 17 31 32 30 37 34 27 31 42 36 43 35 39 31 25 17 14 46 47 485 516 23 12 13 24 10 14 18 9 7 8 19 11 12 23 11 11 13 8 9 10 10 4 19 16 11 15 6 6 30 19 230 210 22 28 23 28 22 32 17 22 32 20 27 27 23 20 27 21 26 37 25 24 27 31 22 21 17 16 14 11 70 36 424 402 47 71 73 79 71 94 70 43 55 58 61 49 76 83 77 54 84 73 78 68 69 80 79 70 67 68 67 57 222 140 1253 1154 14 18 10 18 29 21 28 23 16 22 15 18 19 15 18 17 27 20 25 38 27 30 28 16 11 17 5 14 18 19 308 328 18 20 27 28 41 37 30 39 11 16 15 19 19 15 26 16 39 43 30 37 34 45 25 33 25 22 13 22 28 19 397 439 29 24 42 31 35 42 20 30 26 23 16 15 16 20 19 24 27 32 39 36 21 26 16 23 18 12 11 14 26 19 383 398 6 13 15 11 18 19 16 20 11 14 10 15 10 8 13 12 19 24 19 18 21 26 22 14 13 21 9 7 19 13 229 243 36 24 26 33 39 49 27 33 20 22 20 20 23 26 35 40 36 34 26 43 33 38 28 33 32 31 26 18 41 39 464 509 5 3 6 6 17 13 15 18 10 13 5 7 7 9 17 22 22 21 27 28 22 20 20 24 23 20 14 14 40 23 257 247 16 16 11 11 23 13 24 26 13 23 15 18 21 22 15 19 28 16 23 31 18 22 18 16 12 15 14 10 82 34 347 311 23 22 33 29 34 44 25 32 16 19 12 19 28 20 32 29 36 32 50 55 37 33 29 35 28 33 32 31 24 30 457 491 28 44 37 45 45 52 35 34 26 34 35 31 27 27 38 40 37 44 44 42 47 52 38 36 24 34 23 28 86 54 608 636 22 21 33 30 30 27 16 22 15 23 27 19 25 24 27 35 26 30 22 20 27 20 14 13 17 15 17 15 39 17 376 360 DistrictEast2Totals F 305 318 M 368 351 390 415 451 490 368 391 274 317 298 285 337 344 385 377 454 441 448 492 429 470 393 389 329 344 268 261 771 509 6218 6244 PG: 285 APPENDIX 1 ARHA POPULATION 2008 DistrictWest1 59 1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7074 75+ Total 47 45 52 51 55 48 44 49 56 44 44 52 41 43 57 48 63 50 69 54 52 61 41 45 39 29 40 33 133 89 887 804 16 14 16 23 16 16 7 16 10 5 10 10 13 9 7 13 13 16 17 9 14 15 13 15 12 11 1 10 9 10 182 206 17 22 21 24 19 28 24 15 25 21 23 22 17 17 22 15 32 31 26 31 35 30 34 31 28 23 34 30 156 86 544 449 13 17 21 14 29 23 14 18 6 11 8 8 16 13 15 9 28 28 24 29 23 27 7 15 8 9 5 1 8 12 236 239 14 11 13 10 12 19 16 13 16 17 16 14 10 5 16 18 19 16 15 13 15 14 14 17 9 12 12 15 51 27 257 238 10 14 13 25 24 28 18 26 5 7 10 11 14 14 10 16 29 16 39 34 19 33 26 29 17 15 12 18 13 26 268 319 26 12 19 17 16 29 13 15 14 22 18 14 17 17 15 16 15 17 17 23 21 14 13 18 15 15 9 5 19 22 262 274 31 36 29 30 35 28 28 43 23 23 26 22 20 13 23 23 35 29 40 46 23 23 30 23 18 25 17 16 20 20 428 437 43 58 58 57 68 60 46 51 42 53 58 46 51 51 62 52 68 60 61 64 52 40 54 50 54 44 58 38 162 95 994 878 15 28 22 22 25 29 26 26 20 21 18 14 14 12 20 18 34 35 30 32 19 23 19 18 13 13 13 12 18 20 322 350 15 16 12 27 19 24 5 15 7 13 9 8 14 9 23 17 14 24 22 20 18 29 11 12 15 12 8 11 11 13 212 258 DistrictWest1Totals F 249 247 M 278 273 276 300 318 332 241 287 224 237 240 221 227 203 270 245 350 322 360 355 291 309 262 273 228 208 209 189 600 420 4592 4452 Age 04 BoissevainTown F 54 M 63 CameronRM F 8 M 14 DeloraineTown F 31 M 23 GlenwoodRM F 11 M 5 HartneyTown F 9 M 17 MortonRM F 9 M 7 OakLakeTown F 15 M 18 SiftonRM F 30 M 37 SourisTown F 57 M 59 WhitewaterRM F 16 M 27 WinchesterRM F 9 M 8 PG: 286 APPENDIX 1 ARHA POPULATION 2008 DistrictWest2 Age 04 AlbertRM F 4 M 8 ArthurRM F 3 M 8 BrendaRM F 16 M 10 DalyRM F 8 M 3 EdwardRM F 12 M 14 ElkhornVillage F 32 M 16 MelitaTown F 31 M 30 OakLakeSiouxFN F 5 M 12 PipestoneRM F 41 M 40 RiversTown F 45 M 48 SiouxValleyFN F 50 M 46 VirdenTown F 80 M 103 WallaceRM F 27 M 35 WaskadaVillage F 5 M 14 WoodworthRM F 16 M 18 59 1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7074 75+ Total 6 4 4 6 12 11 9 6 7 5 7 10 4 6 11 8 12 10 10 12 18 19 14 21 8 9 4 6 8 14 138 155 6 10 13 17 14 25 10 12 7 5 8 7 6 9 21 11 16 23 20 19 19 19 20 15 14 25 8 9 13 10 198 224 9 17 20 23 18 19 20 26 6 11 14 19 13 12 15 14 22 26 28 29 21 20 15 25 9 10 7 6 23 22 256 289 10 10 22 14 32 31 24 15 8 8 8 11 10 9 21 15 28 41 26 30 15 12 26 23 19 20 12 14 26 24 295 280 15 5 18 22 21 26 23 18 20 15 7 14 12 13 16 13 19 24 38 27 28 28 21 22 10 11 12 10 35 31 307 293 22 24 22 24 19 26 23 24 15 12 13 16 24 13 17 22 27 11 13 22 17 16 14 10 13 12 16 12 51 27 338 287 41 36 38 39 33 29 21 24 20 21 33 38 42 21 31 33 36 44 32 38 35 23 30 37 36 29 25 16 102 54 586 512 7 9 3 9 11 15 11 13 9 9 5 5 5 10 13 6 12 11 7 6 3 5 0 4 7 1 2 7 3 2 103 124 34 37 59 56 64 51 54 46 39 49 35 36 40 38 55 44 48 56 55 68 56 65 39 34 36 32 34 39 106 80 795 771 44 46 49 62 54 48 45 36 43 37 49 32 55 48 48 50 43 38 44 45 35 39 38 34 31 26 22 17 84 60 729 666 28 35 35 33 44 43 45 37 27 35 28 30 28 25 22 37 25 27 25 20 14 12 14 17 8 9 6 6 8 5 407 417 95 93 107 97 110 84 104 105 112 92 80 79 93 97 113 100 110 108 110 120 95 81 89 76 79 63 60 49 286 160 1723 1507 34 37 40 53 57 87 40 57 17 36 23 29 39 36 28 40 66 70 59 57 40 47 56 52 43 45 32 32 61 62 662 775 5 4 2 4 6 5 5 3 6 3 4 8 3 2 3 8 8 9 9 8 4 4 10 7 7 7 4 6 11 9 92 101 17 24 33 21 22 30 24 31 17 24 19 23 18 22 29 24 25 28 41 43 33 40 27 28 26 21 16 16 32 27 395 420 DistrictWest2Totals F 375 373 M 405 391 465 480 517 530 458 453 353 362 333 357 392 361 443 425 497 526 517 544 433 430 413 405 346 320 260 245 849 587 7024 6821 PG: 287 APPENDIX 2 !" "# "$ " % & ' ( ) $ '* " + 0000000000000000000000000000000000000000 )2 3 4 ' & '' ') '& '( ',) ''& ')( ',- # . / 1/1/ " , ( ' $ ) 3 & 4 ''5 #/ " 6/#/#/# 5/// 7. '$ '3 '4 ' (6" 7 8 ')7# " " #5 "'$ / //" / / $ " 9" 6" : ; YOUTH HEALTH SURVEY 32 #" """ < *" = * 4 > < < !!" # 7 , ' ) & ( , '$ &, ($ 7 * 2 * 8 , , , , , , , ' ' ' ' ' ' ' ) ) ) ) ) ) ) & & & & & & & ( ( ( ( ( ( ( , , , , , , , '$ '$ '$ '$ '$ '$ '$ &, &, &, &, &, &, &, ($ ($ ($ ($ ($ ($ ($ '&2 #" " ! % PG: 288 APPENDIX 2 '(5 #/ 5 9" < 6" 5 -# '7# */ /C/" /# " # '$7# " " #5 "'$ / // " // !!" # 7 , ' ) & ( , '$ &, ($ 7 * 2 * 8 , , , , , , , ' ' ' ' ' ' ' ) ) ) ) ) ) ) & & & & & & & ( ( ( ( ( ( ( , , , , , , , '$ '$ '$ '$ '$ '$ '$ &, &, &, &, &, &, &, YOUTH HEALTH SURVEY ($ ($ ($ ($ ($ ($ ($ 7 * 2 * 8 ! ' 5 #/ /# 1 #5#/D % ; ' 8'3 84'& '( ),5 #/ # % ; ' 8'3 84'& '( )'< B"" + " #$% '32 #" " ! % '45 #/ E 5 9" < 6" 5 -# 2 A #" *" "" ));& # 000000000000000000000000000000000000000000 000000000000000000000000000000000000000000 000000000000000000000000000000000000000000 5 PG: 289 APPENDIX 2 )&8 / # 2# 2# # 3 $ "$ ' )(5 #/ # ',,F"B 8.+&# 0000 )$5 #/ "" "B 0000 )35 #/ " 0000 )45 #/ " <" "/"/ 0000 )5 #/ " 0000 ) 5 #/ " // 0000 &, 7 00000000000000# &' 7 0000"000 0000 * &) #/B" "" ! %5"/G(' &&# ! % YOUTH HEALTH SURVEY &(#',, " ! % &$* # &,<# /B""" !1 > 6 ') % &3<# 5 !/ # !/ &, !/ . !/ !/5A %/5# &4 5 " 5 "" 5 " - +000000000000000000000000000000000 &5"/ ) E41''/7/ @ @C# :CC" 9 8 - +000000000000000000000000000000000 5 & 5 / / "# % ; "" 6 "" 7 "" 6 5 (,!" "# "$ "# % & ' ( ) $ PG: 290 APPENDIX 2 ('%"/ # , & ' ( ) $ ()< #// // #1" <" ? ? <" (&< " #"" ! % 5A# ((< &,/ #" , ') &$ 3 ',' ),) 6&, ($< &,/ $#" " , ') &$ 3 ',' ),) 6&, (3< &,/ //B// / //C / "" , ') & ',' ),& (, YOUTH HEALTH SURVEY (4 " " 5" 5"5" 5 5"" (5/ / >. @ 8 ? ( 5/ / # 6 6 9 $,<"+ 6 $'< ') /" " ! % !"#$! %#& ##'#( PG: 291 APPENDIX 3 COMMUNITY ENGAGEMENT CommunityEngagementMeetingsAttendance Communityengagementmeetingswereconductedinthefallandwinterof2009inthe followingcommunitiesandwiththelistedpartners: Community EngagementMeetings ValidationMeetings Kenton 50 9 CypressRiver 32 2 Cartwright 18 4 Foxwarren 21 7 Pierson 21 3 Cromer 20 3 Newdale 38 3 Brookdale 22 1 Eden 12 Minto 19 1 Note:TheEdenvalidationmeetingwascancelledduetolackofinterest/availability Othercommunityengagementactivitiesincluded: Activity Population KeyInformantInterviews 11businesses/workplaces,AddictionsFoundationof Manitoba,AlcoholicsAnonymous,ManitobaAgriculture& Foods,Farm&RuralStressLine,Youth Community/PartnerFocusGroups 2FirstNationcommunities,Women’sInstitute,7Hutterite Brethrencommunities,OldOrderMennonitecommunity, newimmigrants,studentservicescoordinators StaffFocusGroups EMS,FamiliesFirst,HealthPromotion,HomeCare,Mental Health,PalliativeCare,SpiritualHealth,PrairieHealth Matters,PublicHealth,RegionalCoordinatorsCommittee (Acute&LongTermCarefacilities),SupportServicesfor Seniors Surveys OtherActivities/Partnerships Staffsurvey,YouthHealthSurvey,AdultHealthSurvey AboriginalHealthTransitionFundprojects PG: 292 APPENDIX 3 COMMUNITY ENGAGEMENT QuestionsfromtheCommunityEngagementMeetings Whatcontributestohealthandhealthylivinginthecommunity?Ifyouhavetime, describehowthesecontributetohealth. Whatarethemostimportantfactorsthatmustbeaddressedtoimprovethehealth andqualityoflifeinthecommunity? Ifyoucouldimproveonethinginthecommunityrightnow,whatwoulditbe? Whatistheroleofcommunitymembersinbuildingahealthycommunity? Whatwouldexcitepeopletobemoreinvolvedinimprovingthecommunity? Pleasehaveyourspokespersonhighlighttheonetotwomostimportantpointsfromeach question. PG: 293 APPENDIX 4 STAFF SURVEY TheBoardoftheAssiniboineRegionalHealthAuthorityinvitesyoutocompletethisbrief survey for the Community Health Assessment, or CHA. Gathering staff opinions is importantforacompletepicture,asisgatheringopinionsfromthepeopleweserve.This survey gives everyone the chance to provide your thoughts without having to disrupt yourschedulestoattendmeetings.Youmaycompletethissurveyonlineoronpaper. Tocompletethissurveyonline,justclickonthelinkbelowandfollowtheinstructions. Ifyouwishtocompletethissurveyonpaper,pleasesenditbyfax(7593127)orLabTruck toAmyRogaskyattheARHARegionalOfficeinShoalLake. Wewouldaskthatallsurveysbereturnedby:April30,2009sothatyouranswerswill beincludedintheanalysisfortheCHAReport. Tocompletethissurveyonline–Clickonthislink. ONLINESURVEY STRONGLY DISAGREE DISAGREE NEITHER AGREENOR DISAGREE ARHAresidentsknowwheretogoforhealthservices. AGREE STRONGLY AGREE TheARHAprogramsandservicesareresponsiveto theneedsofcommunities. ARHAprogramsandservicesworkwelltogetherto meettheneedsofpatients/residents/clients. WhatdoARHAprograms&servicesdowelltomeettheneedsofpatients,residentsor clients? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Whatisthemostimportantthingweasahealthcaresystemcandotoimprovethe healthandqualityoflifeforpeopleinourcommunities? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ PG: 294 APPENDIX 5 CHA INDICATOR LIST CHAReportIndicatorIndex Category Ref. CorevsNon No. CorevsOther IndicatorName PageNumbersWhere IndicatorReported Dimension:PopulationHealth B.FunctionalStatus C.Health/Social Conditions B2 Core SelfratedHealth 73 B3 Core SF36FunctionalPhysicalHealth 74 B4 Core SF36FunctionalMentalHealth 219 B5 Other Prevalenceof: AHD,ADHD,Disabilities,CongenitalHeartDefects 240 C1 NonCore HighBirthWeight 181 C2 NonCore LowBirthWeight 181 C4 Core PretermBirthRate 183 C5 Other SizeforGestationalAge 182 C6 Core ArthritisTreatmentPrevalence 104 C7 Core Osteoporosis 105 C8 NonCore AsthmaPrevalence 101 C9 Core TotalRespiratoryMorbidityTreatmentPrevalence 99 C10 Core CancerIncidence 108 C13 Core DiabetesTreatmentPrevalence 93 C14 NonCore LowerLimbAmputationduetoDiabetes 96 C15 Core HypertensionTreatmentPrevalence 79 C16 NonCore AcuteMyocardialInfraction(AMI)IncidenceRates 83 C17 IschemicHeartDiseaseTreatmentPrevalence 82 C18 Core StrokeIncidenceRates 90 C19 Core InjuryHospitalizationRates 162 C22 Core TreatmentPrevalenceof:MentalIllnessCumulativeDisorder 225 C23 Core TreatmentPrevalenceofDepression 213 C24 Core TreatmentPrevalenceofAnxietyDisorders 226 C25 Core TreatmentPrevalenceofSubstanceAbuse 231 C26 Core TreatmentPrevalenceofPersonalityDisorder 229 C27 Core TreatmentPrevalenceofSchizophrenia C28 Core TreatmentPrevalenceofDementia 230 227 C29 Core ProportionofAdolescents/TeenagersonSSRIs&stimulants 239 C30 NonCore CommunicableDiseaseOutbreaksfor: EColi Salmonella Shigella 209 C31 CulturalIndicators Core NonCore 20 PG: 295 APPENDIX 5 Category D.Mortality Ref. CorevsNon No. CorevsOther IndicatorName CHA INDICATOR LIST PageNumbersWhere IndicatorReported D1 NonCore TotalMortalityRate 117 D2 Core InfantMortality 187 D3 Other Top5CausesofInfantMortality 187 D4 Other ChildMortality 188 D9 Core UnintentionalInjuryDeaths D10 Core SuicideRates 242 D12 Core LifeExpectancy 124 D13 Core Top5causesofMortality 117 D15 Core PrematureMortalityRates 121 D18 NonCore MortalityRateComparisonsofthosewithandwithout: hypertension arthritis totalrespiratorymorbidity(TRM) diabetes ischemicheartdisease(IHD) cumulativementalillness(CMI) osteoporosis(50+years) 120,189C D20 NonCore PotentialYearsofLifeLost(PYLL)duetoalldeaths 81 104 100 95 83 243 105 124 D21 NonCore PotentialYearsofLifeLost(PYLL)duetoallcancerdeaths 127 D22 NonCore AllCirculatoryDiseaseDeathsPotentialYearsofLifeLost(PYLL) 127 D23 NonCore AllRespiratoryDiseaseDeathsPotentialYearsofLifeLost(PYLL) 127 D24 NonCore UnintentionalInjuryDeathsPotentialYearsofLifeLost(PYLL) 127 D25 SuicidePotentialYearsofLifeLost(PYLL) 127 NonCore Dimension:DeterminantsofHealthandSocialWellBeing E.HealthBehaviours E1 Core BodyMassIndex(InternationalStandard) 55 E2 Core Nutrition:FruitandVegetableConsumption 59 E3 NonCore FrequencyofHeavyDrinking 69 E4 Core Smoking 65 E5 Core LeisuretimePhysicalActivity 61 E7 NonCore BreastfeedingPractices(initiation) 185 E8 Core ChildhoodImmunizationRates: 1yearolds 2yearolds 7yearolds E9 Core AdultInfluenzaImmunizationRates 206 E10 Core AdultPneumococcalImmunization 207 E12 Other Ageatfirstpregnancy 178 E13 Core SexuallyTransmittedInfections:Chlamydia 211 E14 Core SexuallyTransmittedInfections:Gonorrhea 211 201,202,203 PG: 296 APPENDIX 5 Ref. CorevsNon No. CorevsOther Category E.HealthBehaviours (cont.) CHA INDICATOR LIST IndicatorName PageNumbersWhere IndicatorReported E15 Core SexuallyTransmittedInfections:HIV 211 E16 Core BreastCancerScreening(Mammography) 113 E17 Core CervicalCancerScreening(PAPSmears) 114 E22 NonCore AntidepressantUse 237 E23 Other PrescriptionDrugUsebyChildren 239 F2 Core IncomeInequality:IncomeStatus(LICO) 44 F3 Core IncomeInequality:MedianincomeofIndividuals&Households 41 F4 NonCore IncomeAverageHouseholdIncome 43 F8 NonCore PercentageofPopulationScoringHighonWorkStressScale 221 F9 Core UnemploymentRates 45 F10 NonCore YouthUnemployment 47 F11 NonCore HighSchoolCompletion 32 F12 Core EducationLevel 32 F13 Core HousingHousingAffordability 48 F16 NonCore NumberIndependentSeniorLivingBeds(communityhousing55+) 252 F17 NonCore Adolescent/TeenagePregnancyRates 178 F18 Core TeenBirthRates 184 G.Environmental Factors G1 Core SecondhandSmokeExposure 67 H.PersonalResources H1 NonCore LifeStress 221 H4 NonCore SocialSupport:MaritalStatus 51 H6 Core "ReadinessforSchool"Indicatorsfrom"EDI" 36 H7 Other Generalinformationonkindergartenchildrenfrom:EDI"results 38 H9 Core SchoolChanges 39 F.SocioEconomic Conditions Dimension:Governance(RHAGovernanceforCHA) J.Leadership J1 NonCore NewPrograms/Servicesorprogram/servicerevisionasaresultof findingsof2004CHA 267 PG: 297 Category APPENDIX 5 Ref. CorevsNon No. CorevsOther CHA INDICATOR LIST IndicatorName PageNumbersWhere IndicatorReported Dimension:HealthSystemPerformance N1 Core OperationalHospitalBedsper1000Residents 150 N2 NonCore AcuteCareOccupancy 151 N5 Core In&OutFlowofRHAInpatients 155 N6 Core UseofPhysicians 133 N7 Core AmbulatoryVisitRate 134 N8 Core AmbulatoryConsultationRates 136 N9 NonCore AmbulatoryVisitRatetoSpecialists 138 N10 Core WhereRHAResidentswentforvisitstoGP/FPs 135 N11 Core WhereRHAResidentswentforvisitstoSpecialists 140 N12 Other TravellingtoGiveBirth 167 N13 Core FamiliesFirstProgramRiskFactors,i.e.the%offamilieswith newborns: with3ormoreriskfactors alcoholusebymotherduringpregnancy maternalsmokingduringpregnancy maternaldepressionandanxietydisorderscombined incomesupportorfinancialdifficulties motherwithlessthangrade12education. 190 N14 Core ScreeningForandUseofFamiliesFirstProgram 191 Core SupplyofPCHBeds 253 N20 NonCore EMSResponseTime 146 N24 NonCore PrimaryHealthCareInitiativePrograms 129 N25 NonCore Translation&InterpretiveServices 266 O.Safety O1 NonCore StaffFluImmunization 271 P.WorkLife P2 NonCore StaffOrientation 270 P4 NonCore PerformanceManagementProcess 270 P9 NonCore InternalNewsletters 266 P10 NonCore InformationResources 266 P12 NonCore StaffEducationActivities 272 P13 NonCore RHASupportofEmployees'ProfessionalCompetencyRequirements 272 P18 NonCore StaffSatisfactionSurvey 268 P20 NonCore ExitInterviews/Surveys 266 Q1 NonCore AnnualGeneralMeeting(AGM) 266 Q2 NonCore EasilyAccessibleInformationonServicesbyCommunity 266 Q5 NonCore SpiritualCareServices 173 Q6 NonCore PalliativeCareServices 245 N.Accessibility N15 Q.ClientCentred Services PG: 298 Category Q.ClientCentred Services(cont.) R.ContinuityofServices T.Effectiveness APPENDIX 5 Ref. CorevsNon No. CorevsOther CHA INDICATOR LIST IndicatorName PageNumbersWhere IndicatorReported Q7 NonCore RespiteCareServices 236 Q9 NonCore ResultsofRHAInitiatedClientSatisfactionSurveys 268 Q10 NonCore ComplaintManagementProcess 268 R1 Core ContinuityofCare 137 R2 Core AntiDepressantPrescriptionFollowUp 238 R3 Other AsthmaCare:ControllerMedication 102 R4 Other Diabetescare:eyeexams 95 R5 Other Potentiallyinappropriateprescribingbenzodiazepinesforolderadults 249 T1 Core AmbulatoryCareSensitiveConditions 161 T2 NonCore PostMyocardialInfractionCare:BetaBlockers 85 T3 NonCore 30dayInHospitalAMIMortalityRate 85 T4 NonCore 30dayInHospitalStrokeMortalityRate 91 T6 Core 112 T7 Core CancerSurvivalRates: allcancers melanoma colorectal breast cervical prostate lung ReadmissionRateforAcuteMyocardialInfarction T9 Core CaesarianSection 167 T10 Core VaginalBirthafterCaesarianSection 168 T16 Core Hysterectomy 165 T17 Core Tonsillectomy/Adenoidectomy 164 T19 NonCore HealthLinksContact 142 85 Dimension:HealthSystemCharacteristics U.Demographics U1 Core PopulationAttributesPopulation 9 U2 Core PopulationPyramids 12 U3 Core PopulationProjections 14 U4 Core PopulationAttributesDependencyRatio 15 U5 Core PopulationAttributesAboriginalPopulation(byregion) 20 U6 Core PopulationAttributesLoneparentFamilies 52 U7 Core PopulationAttributesLanguageSpoken intheHome 29 U8 Core Internal/ExternalMigration 27 U9 Core GeographicAttributesInternalMigrantMobility 29 PG: 299 Category U.Demographics(cont.) APPENDIX 5 Ref. CorevsNon No. CorevsOther IndicatorName CHA INDICATOR LIST PageNumbersWhere IndicatorReported U10 Core GeographicAttributesUrbanPopulation 30 U11 Core GeographicAttributesPopulationDensity 30 V1 Core PhysicianVisitRatesbyTop10Causes 131 V2 Core PhysicianVisits'for'MentalIllnessDisorders: fromacutecarehospitals frommentalhealthcentres 236 V4 Core TotalHospitalSeparationRates 151 V7 Core 233 V8 NonCore SeparationsforMentalIllnessDisorder,from: acutecarehospitals mentalhealthcentres. SeparationsbyCause 235 V9 NonCore TotalHospitalDaysUsed 157 V10 Core HospitalDaysUsed: ForShortStays ForLongStays 159 160 V14 Core HighProfileProcedures:CataractSurgery 165 V15 Core HighProfileProcedures: HipReplacementSurgery 169 V16 Core HighProfileProcedures:KneeReplacementSurgery 169 V17 Core HighProfileProcedures:CardiacCatheterization 86 V20 Core PercutaneousCoronaryInterventionRates 86 V21 Core HighProfileProcedures:CoronaryArteryBypassGraft(CABG) Surgery 89 V22 Core HomeCare:NewCases("Incidence") 246 V23 Core HomeCare:OpenCases("Prevalence") 247 V24 Core HomeCare:CaseClosingRates 248 V25 Core HomeCare:AverageLengthofHomeCareCases 249 V27 Core PCHUtilization:LevelofCareonAdmission 255 V28 Core PCHUtilization:MedianLengthofStayatPCH,bylevelofcare 258 W.HumanResources W7 Noncore VolunteerContribution 273 X.SystemCapacity X2 Noncore RegionalResearchRelativetoPopulationHealth 267 X3 Noncore RegionalCapacitytoConductResearch 267 Y1 Core PercentOperatingBudgetSpenton: Acute PCH CommunityCosts 265 V.Utilization Y.Fiscal CorporateOffice 1921stAve.West Box579Souris R0K2C0Manitoba RegionalOffice 344ElmStreet Box310,ShoalLake R0J1Z0Manitoba

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