Download A Look at Diabetes in The Pas, the Opaskwayak Cree Nation, the

A Look at Diabetes in The Pas, the Opaskwayak Cree Nation, the R.M. of Kelsey and
Surrounding Region
By: Amanda Donohoe
Home for the Summer Program - May to August, 2014
The Pas, MB
Supervisor: Dr. Kouroush Harandi
Abstract
Diabetes has become a serious health problem for many people living in the Northern Health
Region of Manitoba, including the town of The Pas, the Opaskwayak Cree Nation, the R.M of
Kelsey, and the surrounding communities who rely on many of the same regionally based health
care services. Given the human, financial, and societal burden that this disease is clearly placing
on individuals and communities in the area, along with the provincial and federal governments,
the causes, risk factors, and initiatives affecting the diabetes epidemic in the area deserve
increased examination. This paper will examine some of the issues that are contributing to
increasing diabetes rates in the area, as well as to outline the efforts of the main regional
diabetes programs that are working to slow the spread and negative impacts of the disease. In
addition, some of the key ongoing issues that are hindering diabetes prevention, education, and
management initiatives in the area, as well as some potential solutions, will be discussed.
Introduction
The Pas is a small community located approximately 630 kilometers northwest of Winnipeg, and
is home to just over 5000 people, not including the 2200 people who live in the Rural
Municipality of Kelsey that surrounds the town.1 Just across the Saskatchewan River from The
Pas lies the Opaskwayak Cree Nation (OCN), a federal First Nations reserve that is home to
around 2500 on-reserve members and several thousand more who live off-reserve in The Pas or
elsewhere.2 These communities, as well as several neighbouring subdivisions, small towns and
First Nations reserves in the surrounding area, are members of the former NOR-MAN Regional
Health Authority, which is now located within the borders of the newly incorporated Northern
Health Region in the province. Many of the medical services and facilities that the citizens of
these former NOR-MAN communities rely on are located in The Pas, in spite of their often
significant geographical distance from the town. It was therefore possible, while working at the
St. Anthony’s Hospital during the Home for the Summer Program, to meet and interact with
clients from communities hundreds of kilometers away.
After spending just a few short weeks working in the hospital both in a family medicine clinic
and the emergency department, it became quite obvious that, in spite of the unique geographical,
historical, cultural, and socio-economic characteristics that these different communities possess,
they all had at least one major health problem in common – diabetes. Diabetic patients from all
walks of life, Aboriginals and non-aboriginals, young and old, were steadily presenting to the
hospital for primary care or emergency services on a daily basis. The disease was also present
1
Statistics Canada. 2012. “Focus on Geography Series, 2011 Census - Census subdivision of The Pas, T Manitoba.” Statistics Canada Catalogue no. 98-310-XWE2011004. Ottawa, Ontario. Analytical products, 2011
Census. Accessed July 2014 via http://www12.statcan.gc.ca/census-recensement/2011/as-sa/fogs-spg/Facts-csdeng.cfm?LANG=Eng&GK=CSD&GC=4621045
2
Ibid, and Opaskwayak Cree Nation [website]. 2014. “Community Profile.” Accessed July 2014 via
http://www.opaskwayak.ca/communityprofile.php
1
throughout the wards, with diabetic patients filling many of the acute care beds and dialysis
chairs within the facility, or requiring home-care services. Although troubling, this trend was not
surprising, as it has been well established that the Northern Health Region has a diabetes
incidence rate that is double that of any other health region in the province.3 With such a heavy
burden being placed on the regional health care system by this disease, it becomes important to
question why the incidence of diabetes is so high in the region, as well as to find out what is
currently being done outside of an acute care or physician clinic setting to try and manage or
prevent diabetes within the communities themselves.
This paper will therefore examine the main primary care programs and government initiatives
operating out of The Pas/OCN and R.M. of Kelsey, namely the Regional Diabetes Program run
by the Northern Health Region, and the Aboriginal Diabetes Initiative run through the Cree
Nation Tribal Health Centre, that are attempting to slow the spread of diabetes and to mitigate
some of the more damaging effects of the disease within these and nearby communities. Ongoing
problems and challenges faced by these programs will also be discussed, as well as some
possible ideas for improvements. First, however, a brief overview of how and why diabetes is so
profoundly affecting the people of northern Manitoba will be undertaken.
Diabetes in the Northern Health Region – Issues and Contributing Factors
Manitoba has some of the highest rates of diabetes in the country,4 with approximately 94,000
people being diagnosed with Type 1 or Type 2 diabetes in 2010.5 With this number expected to
3
Fransoo R, Martens P, The Need To Know Team, Prior H, Burchill C, Koseva I, Bailly A, Allegro E.
October 2013. “The 2013 RHA Indicators Atlas.” Manitoba Centre for Health Policy: Winnipeg, MB, p. 85.
4
Public Health Agency of Canada. 2011 “Diabetes in Canada: Facts and figures from a public health
perspective.” Ottawa, ON, p. 16. Accessed online July 2014 via http://www.phac-aspc.gc.ca/cd-mc/diabetesdiabete/index-eng.php
2
rise to 139,000 by 2020, which is around 10.1% of the Manitoba population, the province will be
expected to carry a financial burden of nearly $640 million per year of direct and indirect costs
from the disease. As noted above, the Northern Health Region, which spans the entire top half of
Manitoba, has the highest rates of diabetes of all the health regions in the province, the majority
of which is related to Type 2 diabetes. According to recent provincial age and sex-adjusted data,
prevalence rates of over 20% of residents aged 19 and over were seen between 2009/10 and
2011/12 in the region, and this number is expected to continue to rise.6 The diabetes prevalence
rate in The Pas/OCN and the R.M. of Kelsey specifically (excluding the surrounding
communities and reserves) echoes this regional rate, nearing 18% during the same time period.7
That being the case, it is clear that the Northern Health Region and the province will face major
challenges as it attempts to deal effectively with the financial, health, and societal consequences
of diabetes in the north in the years to come.
A variety of factors are likely contributing to the high incidence of diabetes in the Northern
Health Region, one of which involves the high Aboriginal population in this part of the
province.8 Although diabetes rates vary widely between different First Nations, Metis, and Inuit
groups throughout the country, with crude prevalence rates ranging from 2.7 to 19% or higher in
some cases, it has been relatively well established that many Aboriginal groups, First Nations
peoples in particular, tend to have significantly higher diabetes rates than the general
5
Canadian Diabetes Association. 2009. “The Cost of Diabetes in Manitoba.” Publication sponsored by
Novo Nordisk Canada Inc, p. 3-4. Accessed online July 2014 via
http://www.diabetes.ca/CDA/media/documents/publications-and-newsletters/advocacy-reports/cost-of-diabetes-inmanitoba.pdf
6
Fransoo R, Martens P, The Need To Know Team, Prior H, Burchill C, Koseva I, Bailly A, Allegro E.
October 2013. “The 2013 RHA Indicators Atlas.” Manitoba Centre for Health Policy: Winnipeg, MB, p. 86.
7
Ibid, p. 87.
8
Ibid, p. 85.
3
population.9 Unfortunately, increasing rates of diabetes among Aboriginal youth in the north are
further adding to the burden of disease among these populations and the Northern Health Region
as a whole.10 The reasoning for these higher diabetes rates among Aboriginal peoples is
extremely complex, and is related to a variety of socioeconomic, historical, cultural,
geographical, and lifestyle factors.11 Thus attempts to address the spread and consequences of
the disease within many Aboriginal populations in the north face a wide array of challenges, and
without a distinct and concerted effort by individuals, communities, and provincial and federal
governments to address these challenges, it is likely that diabetes rates will continue to rise.
However, although it is clear that Aboriginal peoples in the Northern Health Region are being
affected disproportionately by the diabetes epidemic, with a specific concern being placed on the
incidence of Type 2 diabetes, many of the same factors that are affecting their risk levels for the
disease are similar to those affecting many other northern residents. For example, issues such as
rural residency, large geographical distances from food sources and health care facilities, higher
food costs and sometimes limited food options, lower incomes, poor diets, sedentary lifestyles,
obesity, and doctor shortages impact the ability of many people in the north to make the best
health choices for themselves, or to access sufficient health care services.12 Today, government
agencies, regional diabetes initiatives, and health care workers in the Northern Health Region are
9
Public Health Agency of Canada. 2011 “Diabetes in Canada: Facts and figures from a public health
perspective.” Ottawa, ON, p. 92. Accessed online July 2014 via http://www.phac-aspc.gc.ca/cd-mc/diabetesdiabete/index-eng.php, and Health Canada. 2011. “The Aboriginal Diabetes Initiative – Program Framework 20102015.” Minister of Health, Ottawa ON, p. 4. Accessed online July 2014 via http://www.healthcanada.gc.ca/ADI
10
Ibid, p. 92, and Brownell M, Chartier M, Santos R, Ekuma O, Au W, Sarkar J, MacWilliam L, Burland
E, Koseva I, Guenette W. October 2012 “How Are Manitoba’s Children Doing?” Manitoba Centre for Health
Policy, Winnipeg, MB, p. 77.
11
Public Health Agency of Canada. 2011 “Diabetes in Canada: Facts and figures from a public health
perspective.” Ottawa, ON, p. 93-99. Accessed online July 2014 via http://www.phac-aspc.gc.ca/cd-mc/diabetesdiabete/index-eng.phpp
12
Ibid, p. p. 30, 34, 71, and Dybaylo, Luba. June 2014. Interview conducted in The Pas, MB. Nurse
Educator with the Regional Diabetes Program, Northern Health Region, The Pas, MB.
4
trying to address all of these different issues, and changing or modifying these risk factors, and
thereby changing the lives of all northern Manitoba residents, will help to stem the progression
of the diabetes epidemic in the years to come.
Key Diabetes Programs in The Pas/OCN, R.M. and Surrounding Area
The majority of diabetic patients in The Pas/OCN and R.M. of Kelsey, as well as Flin Flon,
Snow Lake, Grand Rapids, Easterville, Moose Lake, and Cormorant, are referred to the Regional
Diabetes Program (RDP) once a diagnosis of diabetes or pre-diabetes has been made.13 The RDP
is run out of the Primary Health Care facility in The Pas, and this program employs three nurse
educators that specialize in diabetes, a registered dietician, and two retinal screening nurses
along with a regional coordinator. Together this team works primarily out of The Pas/OCN, but
they also make regular visits to Flin Flon, Snow Lake, and the nursing stations in the four other
communities noted above. Each of the three nurse educators is in charge of managing
programming in specific communities, to help ensure that staff can develop stronger, lasting
relationships with their clients, as well as to allow them to better understand the specific needs
and desires of those particular communities.
The nurse educators and other staff with the RDP provide diabetic clients and their families with
a variety of essential services related to their condition, one of the most important of which is
educating new patients on what diabetes is and how to access and take their medication. Due to
the limited supply of physicians in the region, doctor’s appointments are often short and hard to
come by. Those without a regular family physician or who live in communities without regular
13
Dybaylo, Luba. June 2014. Interview conducted in The Pas, MB. Nurse Educator with the Regional
Diabetes Program, Northern Health Region, The Pas, MB.
5
physician services often find it even more difficult to access care. Moreover, although some
community clinics, such as the Beatrice Wilson Health Centre in OCN, run by the Opaskwayak
Health Authority, have diabetic and foot care nurses on staff, most nursing stations in the region
lack the ability to provide diabetes-specific services. Physicians thus often refer new and
continuing diabetic patients on to the RDP for education on starting a medication or insulin
regimen (including accessing the necessary equipment and supplies), managing their diet and
physical activity, or other issues related to diabetes management instead of providing this
information in their own office. At present, there is no waiting list for patients wishing to access
the RDP, and it is therefore possible for staff to provide longer (1-2 hours as needed) and
multiple appointments for those who need them, as well as allowing for ad hoc phone
consultations as necessary.14
Along with basic diabetes education, client visits to the RDP can result in some minor insulin
adjustments by the nurses (up to two units per visit) or written suggestions to the client’s family
physician regarding medication needs or alterations. The physical condition of patients can also
be followed closely through regular patient consultations with the RPD, with a particular
emphasis being placed on diabetic neuropathies via the retinal scanning program as well as
through foot care education and monitoring. Clients can have their feet checked during their
appointments for signs of neuropathy, and receive advice regarding ulcer formation,
management, and healing as well as daily preventative foot care. Moreover, patients can receive
handouts and information packages regarding the topics or medical issues they discuss during
their visits to help them to better retain information, as well as some samples and equipment,
such as blood sugar monitors, that can be used for the daily management of their condition.
14
Ibid.
6
While individual and family based client care is the main focus of the RDP, prevention and
community education work also form a component of the program. In The Pas/OCN and during
some visits to outlying communities, the RDP staff holds free workshops and information
sessions for community members regarding various issues linked to diabetes prevention and
management, and also provide individual client visits. These workshops provide an opportunity
for all community members to learn, or re-learn, important facts and strategies for diabetes
prevention, and can help to reinforce lessons learned during visits to the RDP, nursing stations,
or family doctors. They also help promote and familiarize people with the RDP services that are
available to them within their communities.
In addition to work done by the RDP, diabetes prevention and education programming is also
provided within First Nations communities in the Swampy Cree Tribal Council area (which
includes OCN) through the Cree Nation Tribal Health Centre (CNTHC).15 The mandate of this
organization encompasses eight different First Nations in the region, and the diabetes-related
work of the CNTHC is funded in large part by the First Nations and Inuit Health branch of the
federal government.16 At present, this funding and current programming direction is derived
from the federal Aboriginal Diabetes Initiative (ADI), which was established in 1999 to order to
begin addressing the high rates of diabetes in hundreds of aboriginal communities throughout the
15
Sinclair, Deanne. August 2014. Phone interview conducted in The Pas, MB. Prevention worker with the
Cree Nation Tribal Health Centre Inc.
16
Cree Nation Tribal Health Centre Inc. “About us.” Accessed July 2014 via
http://www.tribalhealth.ca/abus.htm
7
country. The ADI is currently in its third phase, which will run from 2010 through 2015 and
receive $275 million over the five years in renewed funding from the government.17
Since its inception, the ADI has “aimed to increase awareness of type 2 diabetes, and reduce the
prevalence and incidence of diabetes and its complications among First Nations, Inuit and
Métis.”18 To achieve these goals, funding has been focused on a variety of areas, including
research, surveillance, capacity building, health promotion, screening, treatment, and prevention.
Phase 3 of the ADI, in addition to basic diabetes prevention and health promotion, has
established four areas of “enhanced focus” namely: initiatives for children, youth, parents and
families; diabetes in pre-pregnancy and pregnancy; community-led food security planning to
improve access to healthy foods, including traditional and market foods; and enhanced training
for health professionals on clinical practice guidelines and chronic disease management
strategies.19
In the Swampy Cree Tribal Council area in northern Manitoba, the CNTHC has been
implementing programming through the ADI in part by hiring and establishing ADI workers in
each of the eight communities it serves.20 ADI workers can operate independently or through
established nursing stations and community clinics, and are members of the communities in
which they work. Most of the ADI workers speak Cree as well as English, and they receive
17
First Nations and Inuit Health. 2013. “Diabetes.” Health Canada. Accessed July 2014 via http://www.hcsc.gc.ca/fniah-spnia/diseases-maladies/diabete/index-eng.php
18
Ibid.
19
Health Canada. 2011. “The Aboriginal Diabetes Initiative – Program Framework 2010-2015.” Minister
of Health, Ottawa, ON, p. 6. Accessed online July 2014 via http://www.healthcanada.gc.ca/ADI
20
Sinclair, Deanne. August 2014. Phone interview conducted in The Pas, MB. Prevention worker with the
Cree Nation Tribal Health Centre Inc., The Pas, MB.
8
training and hold debriefing sessions three times a year at the CNTHC in The Pas to discuss new
ideas, ongoing research, effective health promotion strategies, and community events.
At present, the primary goals of CNTHC ADI workers and programming are to improve diabetes
awareness, education, and prevention in Swampy Cree communities, and therefore a variety of
community events and activities are undertaken throughout the year to help promote these goals
and improve health outcomes.21 These activities include community walking derbies, traditional
games, workshops, health fairs, diabetes-themed bingos, ‘Kids in the Kitchen’ food education
programs, and the distribution of educational materials ranging from diabetes care manuals to
diabetes-friendly cookbooks. Ultimately, the CNTHC and ADI workers are working directly
with community members and trying to find culturally relevant, community-based approaches to
tackle the diabetes problems they face, something which will hopefully help to stem the
progression of the disease in the future and improve the lives of those dealing with the disease
today.
Identifying Problems and Looking for Solutions – Working Toward Improved Diabetes
Prevention and Management in The Pas/OCN, R.M. of Kelsey and Surrounding Area
As noted above, a wide variety of issues and lifestyle factors are contributing to the high diabetes
rates that are impacting the citizens and the health system in The Pas/OCN, R.M. of Kelsey and
the surrounding area. However, interviews with healthcare workers from the RDP and the
CNTHC, as well as personal observations and informal conversations with doctors, nurses, and
other hospital staff throughout the Home for the Summer Program highlighted several key issues
which appear to be some of the most significant factors limiting or hindering the effectiveness of
21
Ibid.
9
diabetes initiatives and programming in the area.22 The most commonly raised issue by far, and
usually the first in most conversations, was that of food, and more specifically food access,
education, and security.
When it comes to food in this region of the province, a number of different problems exist that
affect people from all walks of life, including a lack of fresh, healthy food in rural and reserve
grocery stores, high food costs (especially on fresh produce, milk, and meats), poor diet choices,
a lack of knowledge regarding nutrition and cooking, and the low socioeconomic status of many
people in the region, which prevents many families from purchasing sufficient or healthy foods
on a regular basis. With regards to the Aboriginal population in the region in particular, it was
noted by Ms. Sinclair from the CNTHC that if fresh, healthy food does not become cheaper and
more readily available in the grocery stores in First Nations communities, efforts to change
peoples’ dietary habits through dietary advice, training cooking techniques, or nutritional
education will likely be ineffective.23 Moreover, Ms. Dybaylo of the RDP further mentioned that
some of the existing, standard educational materials, as well as some Aboriginal versions, that
they had available for clients were not always entirely appropriate, or necessarily better, for the
needs and lifestyles of the Aboriginal peoples in this region of Manitoba.24
These concerns by local workers regarding food security and access issues are echoed
specifically as an important area of focus for diabetes prevention and management in the ongoing
22
Dybaylo, Luba. June 2014. Interview conducted in The Pas, MB. Nurse Educator with the Regional
Diabetes Program, Northern Health Region, The Pas, MB, and Sinclair, Deanne, August 2014. Phone interview
conducted in The Pas, MB. Prevention worker with the Cree Nation Tribal Health Centre Inc., The Pas, MB.
23
Sinclair, Deanne, August 2014. Phone interview conducted in The Pas, MB. Prevention worker with the
Cree Nation Tribal Health Centre Inc., The Pas, MB.
24
Dybaylo, Luba. June 2014. Interview conducted in The Pas, MB. Nurse Educator with the Regional
Diabetes Program, Northern Health Region, The Pas, MB.
10
ADI Phase 3 Framework, which places an added emphasis on traditional or regional food use.25
Although many changes still need to be made in northern Manitoba communities with regards to
food access and security, some positive initiatives are currently underway to try and better
address food issues in the area. For example, as noted above, the ADI workers in the Swampy
Cree Tribal Council area run food preparation and education programs with children in their
communities on a regular basis, to help teach young people how to cook and to make better food
choices. Moreover, ADI workers and community members are also presently working to create a
culturally relevant, ‘reserve-friendly’ cookbook that incorporates traditional and readily available
foods, which they hope to be able to distribute to community members. These cookbooks will
replace previous diabetes cookbooks they received which were found to be inappropriate for the
finances, diets, and food availability within most Swampy Cree communities.26 If communities
can continue these and other efforts to address food security issues in the future, perhaps by
working with stores and food suppliers directly to adjust prices or food supplies, or by working
to implement standardized, healthy meal plans and food education programs in schools
throughout the region, further gains may be made to help prevent and manage diabetes in the
north.
Another issue which was raised during interviews and observed throughout the course of the
Home for the Summer program was the need for improved communication and collaboration
between physicians and the diabetes nurses in the RDP or other clinics. For example, the need
for the nurse educators in the RDP to have more access to and privileges for modifying patient
25
Health Canada. 2011. “The Aboriginal Diabetes Initiative – Program Framework 2010-2015.” Minister
of Health, Ottawa, ON, p. 6. Accessed online July 2014 via http://www.healthcanada.gc.ca/ADI
26
Sinclair, Deanne, August 2014. Phone interview conducted in The Pas, MB. Prevention worker with the
Cree Nation Tribal Health Centre Inc., The Pas, MB.
11
charts, and greater abilities to order blood/urine tests (e.g. having standing orders for A1C tests)
or prescribe diabetes medications were mentioned as possible areas which could help to expedite
and simplify diabetic patient management, given the challenges of accessing physician services
in the region. Improving access to the RDP by having diabetes clinics located in the hospitalbased or community family medicine clinics was also noted as a potential area of improvement.
At present, patients from all over the region are referred to the Primary Care Centre, but are
presently in charge of making their own appointments and getting to them, something which can
be a challenge for patients outside of The Pas/OCN area. Having a diabetes nurse or worker
present in the clinic available for patients, even on a once weekly or bi-weekly basis for visits
that are coordinated with regularly scheduled physician appointments, could serve to improve
patient compliance with medication, dietary, and self-care regimens.
On a similar note, diabetes service and programming provision to patients could also potentially
benefit from improved collaboration between the different regional diabetes programs such as
the RDP and the CNTHC ADI initiative. During interviews neither the RDP nor the CNTHC
representatives noted any joint ventures or activities with the other organization when asked, in
spite of the fact that they work in many of the same communities on the same diabetes
prevention and care issues. This separation of programming could be leading to the duplication
of services, which could be wasting already scarce resources in some cases. Furthermore,
working together on facilitating community activities, incorporating the different skill sets of the
ADI workers, nurse educators, and other community members, could allow clients to access a
wider variety of services during a single visit or event, rather than needing to attend multiple
events or appointments to receive their desired information or care. While some challenges may
12
serve to impede this kind of collaboration, including separate funding bases (often provincial
versus federal) and scheduling conflicts, efforts to work together could have positive,
constructive impacts on the provision of diabetes programming and education in the region.
Conclusion
In the end, the discussion on what needs to be done to help slow the spread of diabetes in
northern Manitoba is not one which can be covered in any one paper or research project. The
complexity of the issues contributing to the epidemic in the region is significant, involving every
aspect of society ranging from individuals, families, and communities to the provincial health
system and the federal government. To make matters more complicated, diabetes is an
undeniably complex disease, and one which can cause silent damage to a person’s body for years
before the consequences of mismanaging one’s health and lifestyle becomes apparent.
Ultimately, a long-term process with a concerted effort to address the challenges faced by both
individuals dealing with diabetes and the specific needs of the communities they live in will be
necessary if improvements to the current situation are to be made. Stronger local, provincial, and
federal policy-level leadership and cooperation, along with the continued positive regional
efforts that can be seen through the Regional Diabetes Program run through the Northern Health
Region and the Cree Nation Tribal Health Centre, will all contribute to improved health
outcomes and lower diabetes rates in the future. At present, however, many changes clearly still
need to be made. As such, an increased awareness of the magnitude of the problem in the region,
as well as the multifaceted reasons behind it, will be essential is any significant positive change
13
in the health and lives of northern Manitoba residents dealing with, or at risk of, diabetes is to
become a reality.
14
References
Brownell M, Chartier M, Santos R, Ekuma O, Au W, Sarkar J, MacWilliam L, Burland E,
Koseva I, Guenette W. October 2012 “How Are Manitoba’s Children Doing?” Manitoba
Centre for Health Policy, Winnipeg, MB.
Canadian Diabetes Association. 2009. “The Cost of Diabetes in Manitoba.” Publication
sponsored by Novo Nordisk Canada Inc. Accessed online July 2014 via
http://www.diabetes.ca/CDA/media/documents/publications-and-newsletters/advocacyreports/cost-of-diabetes-in-manitoba.pdf
Cree Nation Tribal Health Centre Inc. 2004. “About us.” Accessed July 2014 via
http://www.tribalhealth.ca/abus.htm
Dybaylo, Luba. June 2014. In-person interview conducted in The Pas, MB. Nurse Educator with
the Regional Diabetes Program, Northern Health Region.
First Nations and Inuit Health. 2013. “Diabetes.” Health Canada. Accessed July 2014 via
http://www.hc-sc.gc.ca/fniah-spnia/diseases-maladies/diabete/index-eng.php
Fransoo R, Martens P, The Need To Know Team, Prior H, Burchill C, Koseva I, Bailly A,
Allegro E. October 2013. “The 2013 RHA Indicators Atlas.” Manitoba Centre for Health
Policy: Winnipeg, MB.
Hallett, Bruce et al. 2000. “Aboriginal People in Manitoba in 2000,” Chapter 2: Health –
Diabetes, Manitoba Aboriginal and Northern Affairs and the Government of Canada: p.
39-42. Accessed July 2014 via http://www.gov.mb.ca/ana/apm2000/2/f.html
Health Canada. 2011. “The Aboriginal Diabetes Initiative – Program Framework 2010-2015.”
Minister of Health, Ottawa ON.Accessed online July 2014 via
http://www.healthcanada.gc.ca/ADI
Opaskwayak Cree Nation [website]. 2014. “Community Profile.” Accessed July 2014 via
http://www.opaskwayak.ca/communityprofile.php
Public Health Agency of Canada. 2011 “Diabetes in Canada: Facts and figures from a public
health perspective.” Ottawa, ON. Accessed online July 2014 via http://www.phacaspc.gc.ca/cd-mc/diabetes-diabete/index-eng.php
Sinclair, Deanne. August 2014. Phone interview conducted in The Pas, MB. Prevention worker
with the Cree Nation Tribal Health Centre Inc., The Pas, MB.
Statistics Canada. 2012. “Focus on Geography Series, 2011 Census - Census subdivision of The
Pas, T - Manitoba.” Statistics Canada Catalogue no. 98-310-XWE2011004. Ottawa,
Ontario. Analytical products, 2011 Census. Accessed July 2014 via
15
http://www12.statcan.gc.ca/census-recensement/2011/as-sa/fogs-spg/Facts-csdeng.cfm?LANG=Eng&GK=CSD&GC=4621045
16