Attendees at the Roundtable for Indigenous Youth, a part of the national OurCare survey, are calling for health services delivered “Auntie Style.”

Throughout the Roundtable, participants were clear that in their interactions with health-care professionals, they want to feel both cared for and respected. In this context, “Auntie Style” means that systems and workers are rooted in the concept of kinship and can provide culturally safe care.

“We walk into a hospital and expect to be discriminated against,” was a typical experience echoed again and again throughout the Roundtable session, with youth expressing a deep mistrust of the mainstream health-care system. Indigenous youth also reported often delaying seeking medical care until it becomes an emergency.

Findings from the Indigenous Youth Report show a need for more Indigenous staff across the health-care system, additional Indigenous-led care and spaces, and accountability. This includes holding all staff accountable for the way they treat patients, especially Indigenous people, so that all patients are treated with dignity in hospital and other medical settings.

The Roundtable was one component of OurCare’s national initiative. Over 16 months, OurCare heard from nearly 10,000 Canadians about their experiences and aspirations for a better primary care system. Collectively, Manitobans contributed about 1,318 hours to OurCare.

Ten community roundtables, including two held in Winnipeg, received in-depth feedback from 192 participants from underserved communities including First Nation, Inuit and Métis people; African, Caribbean and Black communities; immigrants, refugees, migrant workers and other newcomers; LGBTQIA+ migrants; and people with disabilities.

Input from participants at all stages of the project was distilled into the OurCare Standard, six elements of what every person in Canada should expect from the primary care system:

1. Everyone has a relationship with a primary care clinician who works with other health professionals in a publicly funded team.
2. Everyone receives ongoing care from their primary care team and can access them in a timely way.
3. Everyone’s primary care team is connected to community and social services that together support their physical, mental and social well-being.
4. Everyone can access their health record online and share it with their clinicians.
5. Everyone receives culturally safe care that meets their needs from clinicians that represent the diversity of the communities they serve.
6. Everyone is served by a primary care system that is accountable to the communities it serves.

“The national OurCare Standard provides a straightforward and easy to understand guide for what people should be able to expect from the primary care system and what policymakers and decision makers should work towards when making changes to the primary care system,” said Dr. Amanda Condon, OurCare Manitoba co-lead and head of family medicine at the Max Rady College of Medicine, University of Manitoba, and Shared Health provincial specialty lead of family medicine.  “Primary care that meets the OurCare Standard is primary care that meets the needs identified in the Indigenous youth community roundtable convened in Manitoba.”

“I feel that it is very important that each of us do our part to ensure that health care meets the needs of all of our citizens in Canada,” said Marti Ford, a panel member with Inuit and settler roots. Ford is also an assistant professor of education at the University of Manitoba. “Complaining about a system doesn’t solve anything, we need to give our time to find a solution. We are all impacted by the health-care system and it needs to be healed in order to continue the work that the health-care professionals are striving for in a broken system.”

The OurCare report and the Manitoban Indigenous Youth Report are available on the OurCare website.

From June 19 to 22, the master’s student in community health sciences at the Max Rady College of Medicine took part in the institute that’s aimed at providing health research and health professional trainees with the knowledge and skills needed to work towards sustainable health systems.

“We don’t really think about health care being a sector that is a heavy greenhouse gas emitter or wasteful,” Alexiuk said. “You think about the oil sector and things that are poorly affecting the environment, but health care does, and I wanted to learn about it.”

The institute is run by CASCADES, an organization led by the University of Toronto Centre for Sustainable Health Systems that supports Canada’s health-care community to transition towards an environmentally sustainable and resilient health system.

The institute was open to master’s and PhD students in public health, health administration, health services and policy, and health-care professional programs.

While CASCADES is located in Toronto, the two master’s and two PhD students who took part from UM didn’t have to travel to Ontario for the sessions. To avoid travel and be environmental conscious, hubs were set up at 11 universities across Canada to offer a hybrid format.

The morning session featured in-person local experts who spoke about topics ranging from the environmental impact of hospitals to how to reduce the environmental effect of family medicine clinics. The afternoon featured national panels that were broadcast to the hubs digitally.

The summer institute is in its second year but it’s the first year UM students have participated.

Dr. Alan Katz, professor of community health sciences and family medicine at the Max Rady College of Medicine, said he helped establish a hub at UM because climate change is a crucial issue and health care’s impact on the environment is important to him as a health-care provider.

“These graduate students are our future leaders,” Katz said. “Giving these students skills and information is going to help us address climate change in the future.”

One of those future leaders is Dr. Degol Tsegai, a master’s student in community health sciences.

The physician said he learned a lot about how health-care professionals can incorporate the idea of sustainability as part of the quality-of-care piece in their practice. He said that everything from how different drugs impact the environment to waste management in hospitals must be looked at for their impact on climate change and environmental sustainability.

“The summer institute has changed my awareness,” Tsegai said. “I think this is a very important initiative and it will help me in the future.”

If you are interested in taking part in the summer institute next year, you can find more information here: https://cascadescanada.ca/training/summer-institute/.

A key lesson of that journey, she says, is that health is multifaceted, with needs based on physiological, emotional and social factors.

Halas, who was raised in Winnipeg, is an assistant professor in the School of Dental Hygiene at the Dr. Gerald Niznick College of Dentistry, where her academic career started 22 years ago.

Her passion for primary health-care research took hold when, from 2006 to 2016, she was mentored by Dr. Alan Katz [M.Sc./95], working as a research associate in family medicine at the Max Rady College of Medicine. Spurred on by that experience, she completed her PhD in 2016 through UM’s individualized interdisciplinary program.

“I wanted to look not just at health or oral health, but to consider the whole person and the social world immediately outside of the person,” she says. “I thought listening to patients’ experiences and feedback could be pivotal for optimizing the way forward.”

Halas holds adjunct appointments in family medicine and community health sciences. In 2019, she was appointed the inaugural Rady Chair in Interprofessional Collaborative Practice.

Her current research focuses on how different health-care professionals collaborate in providing primary health care. Collaboration, she says, is not the easiest thing to study.

“Collaboration could be a consultation between two health-care providers, or a provider referring a patient to another professional, or people with a range of roles supporting a patient when they leave the hospital.  It’s complex.”

In one of her studies, Halas is looking at individuals experiencing homelessness who are hospitalized at St. Boniface Hospital with heart conditions. When they are discharged, where do they go? How can they settle back into the community in a vulnerable state?

“This is something physicians and social workers have struggled with. So how about something in between? Not a medical unit, but something that helps facilitate the process,” says Halas.

Her team is working with community advisors, including the Salvation Army, to create a hub for accessing peer support and community assistance after being discharged.

Halas is also studying how COVID-19 has changed the way patients access care. She is examining how health-care providers and patients have experienced virtual care, in order to get a sense of how virtual visits might be sustained.

“I was interested in learning about the shifting roles of health professionals during the pandemic. However, that was quite a challenge,” she says.

“Virtual visits are one piece of the health-care system’s capacity. To better examine workforce capacity, we need a data infrastructure with information on the health workforce regarding scope of work, training, and how health teams work together. This has been a long-standing issue in Canada, even predating the pandemic.” 

In all her research, Halas says she wants to focus on the individual patient.

“All the things we do as health-care providers and researchers affect individuals. How does that translate to meaningful and integrated patient care?”

The study, published in the Canadian Medical Association Journal, looked at infections in 16 urban centres, including Vancouver, Hamilton, Quebec City and Winnipeg. Researchers observed concentrations of cases according to social determinants of health, such as income, housing, essential work, visible minority status and more. They found that visible minority status was the social determinant of health that was important across all cities, with variations in the others.

“Social determinants of health have a huge impact on who contracted COVID-19,” said Dr. Alan Katz, an author of the study, and director of the Manitoba Centre for Health Policy (MCHP) at the University of Manitoba. “The results of the study show that people who had higher socioeconomic challenges experienced higher rates of infection and worse outcomes.”

There were 62,709 COVID-19 cases in BC; 15,089 in Manitoba; 239,160 in Ontario; and 215,928 in Quebec recorded in the metropolitan areas that were included in the study. They accounted for 81 per cent, 57 per cent, 83 per cent and 80 per cent of all confirmed cases in each province, respectively.

The study found that Winnipeg did not have as high a concentration of COVID-19 hotspots because of how people live and work in the city, said Katz, professor of community health sciences and family medicine at Max Rady College of Medicine, Rady Faculty of Health Sciences.

“We were a little bit surprised with the magnitude of the difference between Winnipeg and other cities,” Katz said. “But it makes sense when you look at how people live. In other big cities, more people are living in high-rise buildings and in higher density areas. We don’t have those same high-density areas in Winnipeg in the same way. We have areas where people live with significant challenges and poverty, but they’re not living in the high-density conditions which seems to be a key risk factor.”

Katz also said that people in some of the larger cities who didn’t have the option of not going into work or were not eligible for sick leave appeared to live in similar areas that became significant hotspots. Winnipeg did not have this same localized effect, he said.

The study’s findings are consistent with those of other studies from Canada as well as Sweden, the United States and other countries showing higher rates of COVID-19 in racialized communities or diverse neighbourhoods. Katz said that the worse impacts of COVID-19 are on Indigenous people in Manitoba, but in Winnipeg the population is fairly spread out.

“It’s about recognizing that pandemics in particular don’t affect everybody equally,” Katz said. “We need to target our interventions to those who are at most risk, and in this case, it’s very clear that the most at risk people are the people who live with higher socioeconomic challenges.”

The authors call for city-specific public health supports like geographic hot-spot initiatives, such as vaccination rollouts and access to mobile and outreach testing with wrap-around support for quarantine and isolation, that are tailored to effectively reach and meet the prevention and care needs of communities at disproportionate risk of COVID-19.

The researchers analyzed provincial surveillance data from January 2020 to February 2021. The data used for Winnipeg came from the Manitoba Population Research Data Repository held at the MCHP.

“It’s exciting for me because we were invited to join the study because of how good our Manitoba data is,” Katz said. “People from across the country recognize how valuable the MCHP repository data is and they invite us to come join them to do this kind of work using Manitoba data.”

One research team aims to better understand the lingering condition known as “long COVID” and the other to examine, at the cellular level, how a receptor for the disease-causing virus works.

Long COVID

The post-COVID-19 syndrome that some patients experience – a condition called long COVID – is poorly defined, said Dr. Alan Katz, director of the Manitoba Centre for Health Policy (MCHP) and professor of community health sciences and family medicine at the Max Rady College of Medicine in the Rady Faculty of Health Sciences.

Dr. Alan Katz

“This condition is really brand new, and clinicians just don’t know enough about it,” said Katz, the project’s nominated principal investigator. “I’m hoping that we can shine a light on these long-term effects of COVID-19 in a way that can help people deal with this in the future.” 

When a person visits their family doctor with long COVID symptoms – such as fatigue, shortness of breath or cough – it’s not easy for the physician to diagnose the syndrome because there is no test to confirm it, Katz said.

The goal of the study, which received $202,000 from the CIHR for one year, is to help clearly define the risk factors, determine who is more likely to get long COVID and describe the long-term effects of the syndrome. The researchers want to define the kinds of symptoms people are reporting, determine how frequent those symptoms are and provide guidance around diagnosing the condition.

To do this, they will study anonymized health data from the Manitoba Population Research Data Repository held at the MCHP. The researchers will zero in on patients with a COVID-19 diagnosis and follow them, analyzing whether there is an increase in visits to their doctors and tracking their symptoms.

The project’s other principal investigators are Dr. Lisa Lix, professor of community health sciences and Canada Research Chair in methods for electronic health data quality, Dr. Yoav Keynan, associate professor of internal medicine, and Dr. Alex Singer, associate professor of family medicine.

Viral signal transmission inside cells

Dr. Ruey-Chyi Su co-leads a team that will investigate how the binding of the spike proteins of various coronavirus variants to the host-cell receptor known as ACE2 affects viral spread and mortality rates. 

Dr. Ruey-Chyi Su

Little is known about what happens inside cells when the spike protein engages the receptor ACE2, said Su, a research scientist at the Public Health Agency of Canada and adjunct professor of medical microbiology and infectious diseases at the Max Rady College of Medicine.

“This is a much-understudied area,” Su said. “It’s very exciting for us because this grant allows us to study whether the engagement of coronavirus variants with ACE2 triggers different sets of events inside the infected cells, leading to increased viral replication and influencing the severity of the disease.”

The study, which received $430,000 from the CIHR for one year, aims to profile molecular changes caused by the viral spike protein binding to the ACE2 receptor and to identify the changes that are unique to the spike protein of each variant. These changes will be examined in cells from both men and women to determine whether sex has any influence.

The researchers also want to know if the cells of healthy people respond differently to the virus binding to the receptor than the cells of people with chronic diseases, such as diabetes.

“I believe what we find will open up a lot of questions, like, ‘Why do our cells respond differently during a viral infection, and what determines that difference?’” Su said. “The project will increase our knowledge of what to expect during a viral infection and also provide knowledge that might lead to treatments. It’s really a knowledge-building study.”

Su’s co-principal investigator is Dr. James Davie, distinguished professor of biochemistry and medical genetics. The co-applicants are Dr. Brad Doble, associate professor and Bihler Chair in Stem Cell Research in pediatrics, biochemistry and the regenerative medicine program, and Dr. Sandra Gonzalez-Diaz, Su’s post-doctoral fellow.

Members also have a 13 per cent lower risk of being hospitalized, the 10-year retrospective study found.

And members who attend a medical fitness facility more than three times per week exhibit even better health, with a 39 per cent lower risk of hospitalization.

The study, published in the American Journal of Preventive Medicine, is the first to examine the long-term health outcomes of those who attend a medical fitness facility, versus those who don’t.

The project was conducted by researchers at the Chronic Disease Innovation Centre (CDIC) at Seven Oaks General Hospital and the Manitoba Centre for Health Policy (MCHP) in the University of Manitoba’s Rady Faculty of Health Sciences.

“It’s exciting to see this dramatic evidence, based on a large population over a 10-year period, of the benefits of joining a medical fitness facility in preventing disease and premature death,” said Dr. Alan Katz, professor of family medicine and community health sciences, and director of the MCHP.

“These findings provide guidance for health management, and we hope they will inform health policy.”

The Wellness Institute at Seven Oaks General Hospital and the Reh-Fit Centre in South River Heights are not-for-profit facilities that offer a broad range of health, wellness and disease rehabilitation programs. They deliver evidence-based, medically integrated programming and provide a greater degree of medical oversight than traditional fitness centres.

The study focused on more than 19,000 new adult members of the Wellness Institute or Reh-Fit Centre from the time each started scanning their membership card for entry. Their average age was 47.

Members had access to an annual health assessment, fitness equipment, group exercise classes and certified fitness staff. When members swiped in, they may have been accessing services such as nutrition counselling rather than exercising, the study notes.

Using members’ and non-members’ anonymized personal health identification numbers, the researchers used databases at MCHP to compare members’ health status and mortality rate from 2005 to 2015 with those of a control group of nearly 516,000 people from the general Winnipeg population.

Individuals in the control group were matched and directly compared with those in the member group according to age, sex, income (based on postal code) and health conditions. The level of physical activity in the control group was not part of the study.

The researchers conclude that health-care systems should consider the medical fitness model as a preventive public health strategy to encourage physical activity participation. 

“These findings present an opportunity for people to take charge of their health, and for medical professionals and governments to offer a simple option for reducing medical risk,” said Dr. Paul Komenda, professor of internal medicine and research director of the CDIC.

“The medical fitness model holds tremendous potential for public health. Our study found that members tended to be from higher income groups. Imagine if all income groups had regular access to this kind of life-prolonging facility.”

The study received funding from the Seven Oaks General Hospital Foundation, with support from Research Manitoba and the Heart and Stroke Foundation.

View the full infographic of the study findings.

In 2005, MCHP in the University of Manitoba’s Rady Faculty of Health Sciences predicted 1,733 primary care providers would be needed to care for Manitobans in 2020. The study used data in the Manitoba Population Research Data Repository that showed how Manitobans used primary care in the past. The study also factored in how many services, such as patient visits, each provider would be likely to provide and how the Manitoba population would change and grow over time.

A new study, which uses data from 2018, shows the number of primary care providers is within two per cent of what the 2005 study predicted.

“Planning for human resources has traditionally used the number of providers per 100,000 people. We recognized that people of different ages and with chronic diseases require different amounts of care, so we modeled health care use patterns over 30 years to do our predictions,” says Dr. Alan Katz, family physician and director of MCHP.

The study also shows that Manitoba’s population of 1,369,850 grew “a little faster than expected” with over 37,000 more people than was predicted for 2020. It also notes the percentage of female providers has increased from approximately 25 per cent to almost 50 per cent. 

“People who see their primary care provider on a regular basis tend to have better overall health,” says MCHP director Dr. Alan Katz.

Primary care providers, which include family physicians and nurse practitioners, play an important role in keeping Manitobans healthy, Katz says.

“Primary care providers screen for, diagnose and treat illness, and refer patients to specialist doctors when other care is needed. People who see their primary care provider on a regular basis tend to have better overall health. That’s why it’s important to make sure there are enough primary care providers for all Manitobans,” he says. 

Katz says that knowing how well the prediction models work means they can be used to look at future primary care needs. The full report includes projections for primary care resources in all regions of Manitoba up to 2025.

But, he notes we should be careful about assuming that past use of primary care will always reflect what Manitoba will need in the future. 

“Measuring how many people saw their primary care provider doesn’t necessarily tell us whether everyone who needed care was able to access it,” Katz says.

UM Today asked Dr. Alan Katz, the director of the Manitoba Centre for Health Policy (MCHP) to give us a sneak peek into some of the anonymous data it is eager to sort through. MCHP is a research unit within the Max Rady College of Medicine that carries out population-based research on health and social well-being.

UM Today: The population is collectively behaving very differently than it does in “normal” times. What sort of things is MCHP eager to learn about regarding the health effects of these behaviours?

Dr. Katz: MCHP researchers are eagerly awaiting access to data that could be used to answer a multitude of questions. We will need to be patient to answer some of the interesting but less current questions, and there are many of these. For example, we should expect physical distancing to reduce the incidence of infestations, such as lice, and infectious diseases—Manitoba has been experiencing an outbreak of syphilis over the past couple of years so it will be interesting to see what is happening on this front.

What sort of stories do you think the data will tell, mostly positive or mostly negative?

Dr. Katz: Unfortunately, many of the indirect consequences of COVID-19 are likely to be negative. We anticipate increased incidence of family violence, anxiety and depression and even poor outcomes of other chronic diseases that are impacted by mental well-being. In addition, early estimates are that even where virtual doctor visits are being offered, contacts with primary care physicians are down 40%. This suggests that people are not taking good care of their health needs and that there will be consequences.

What do you hope to learn from COVID-19?

Dr. Katz: In the acute phase of the pandemic we want to describe those who are tested and which of them test positive. How do each of these groups compare with the rest of the population on a number of fronts? Are there geographical differences? Socioeconomic and health differences? What about their ages and sex? We have lots of questions that we hope to address to support the public health response to the pandemic.

When might you start having some insights form this work?

Dr. Katz: The public health system is working flat out to deal with the pandemic. We recognize that there are few resources available to get the raw data we need for these analyses. Nevertheless, we are hopeful that the benefit we offer through analyses that would include comparisons with other jurisdictions will be of sufficient interest to make this a priority.

“We need to strengthen our research capacity, especially at a time when there is significant health system change underway,” said Dr. Patty Thille, one of the event’s organizers. “Research capacity, in simple terms, is the ability to carry out research. It involves a range of actions, like enhancing skills and confidence at the individual, teams and community levels.”

In late 2019, Thille, assistant professor of physical therapy in the College of Rehabilitation Sciences, and Dr. Gayle Halas, chair of interprofessional collaborative practice for the Rady Faculty of Health Sciences, co-facilitated a meeting, which was funded and supported by the Manitoba Primary & Integrated Healthcare Innovation Network (MPN). The two-day event that brought together 49 researchers, clinicians, policymakers and community partners from across the province to begin identifying priority actions to build research capacity.

Top priorities identified were a commitment to equity, the creation of a “centre of excellence” that would serve as a one-stop resource for primary health-care research, and establishing a cross-Manitoba network that brings patients, policymakers and community partners together with researchers.

“It is important to develop a health-care system that meets the needs of people wherever they are, as opposed to building models and systems that tend work best for people who already have a lot of resources,” Thille said. “It’s a really relevant topic in Manitoba, where we still have the legacies of colonial oppression and some pretty notable disparities.”

The original planning committee for the initiative that  includes Dr. Jamie Falk, assistant professor in the College of Pharmacy, Dr. Alan Katz, director of the Manitoba Centre for Health Policy, and Dr. Roberta Woodgate, professor in the College of Nursing, has expanded to include MPN’s Policy Lead, Janie Peterson Watt, policy analyst with Manitoba Health, Seniors and Active Living, and MPN’s Clinical Lead, Tamara Buchel, director of postgraduate medical education at the Max Rady College of Medicine.

Going forward, the committee has included two patient partners, Dennis Maione and Mpho Begin, who were part of a group of five that took part in the November workshop.

“Dennis and Mpho were equal members in the discussion with research, clinicians and policymakers,” said Alanna Baldwin, MPN research and operations officer. “They were fully integrated into every aspect of the event as ‘lived-experience-experts.’ They were widely accepted by the other attendees, their opinions were embraced, and they really enjoyed the experience.”

A second conference will be held in the coming months, with exact location and date to be announced soon. There will also be a series of one-hour online discussions, the first of which will take place March 31 and is open to anyone who is interested. Because the discussion is online, it will not be affected by the closures related to the COVID-19 social distancing measures, Baldwin said.

That’s a key finding of a joint study by the First Nations Health and Social Secretariat of Manitoba (FNHSSM) and the Manitoba Centre for Health Policy (MCHP) in the Rady Faculty of Health Sciences at the University of Manitoba.

The study, The Health Status of and Access to Healthcare by Registered First Nation Peoples in Manitoba, compares health data collected in 2015-2017 with the results of a study the MCHP published in 2002.

“When we look at health status and health-care access, the inequities between First Nation people and all other Manitobans have gotten worse, according to many indicators,” said Leona Star, a Cree woman who is director of research at FNHSSM and co-led the study.

In the 2002 report, for example, a First Nation person’s life expectancy was found to be about seven years lower than that of the general Manitoba population. In the new study, that disparity has grown to about 11 years.

A First Nation girl’s life expectancy at birth is now 72 years, while all other Manitoba girls can expect to live to age 84. A First Nation boy can expect to live to age 68, while all other Manitoba boys’ life expectancy is 79 years.

In the 2002 report, First Nation people’s rate of premature mortality (death before age 75) was double that of other Manitobans. That gap has now worsened to being three times the rate for other Manitobans.

The health gap is widening because the underlying factors that negatively affect the health of First Nation people, including the ongoing trauma of colonization, generations of racism, poor housing, lack of clean water and imposed poverty, are not being adequately addressed, said Dr. Alan Katz, director of the MCHP, who co-led the study with Star and Dr. Kathi Avery Kinew of FNHSSM.

“The health of Manitobans is improving overall, but First Nation people are not experiencing the same rate of improvement,” Katz said. “They’re being left further behind and are not being meaningfully involved in decisions on health care.”

The research project is the first in Canada to compare data from a study designed and implemented by First Nation researchers across Canada – the First Nations Regional Health Survey (2015-16) – with data that reports on the health of a representative sample of all First Nation communities in Manitoba, stored in a repository at MCHP.

“This partnership between FNHSSM and MCHP is a sign of progress,” Star said. “It’s essential for First Nation researchers to take leadership roles in studying First Nation health.”

The study was undertaken in response to the Truth and Reconciliation Commission (TRC) Calls to Action, which include a call for gaps in health outcomes to be identified and closed. 

The researchers found that First Nation people, both on-reserve and off-reserve, are medically underserved in many ways. However, they are over-prescribed opioid painkillers – a cause for great concern, the study team said.

Rates of opioid prescribing are more than twice as high for a single prescription, and more than four times as high for multiple prescriptions, for First Nation patients as for other Manitobans. 

Other gaps identified in the study include:

• The suicide rate is about five times higher for First Nation people, while the rate of suicide attempts is five to six times higher;
• The incidence of cervical and colorectal cancer is significantly higher among First Nations, but cancer screening rates are significantly lower among First Nations;
• Continuity of care (seeing the same health professional regularly for primary care) is much lower among First Nations, and they are less likely to be provided care close to home.

The researchers emphasized that First Nation communities are drawing on traditional healing to build people’s resilience and wellness. “Going forward, we need data collection that aligns with the TRC Calls to Action and documents those strengths and positive initiatives, as well as indicators of ill health,” Star said.

The study’s recommendations include:

• Annual reporting on progress in addressing health gaps;
• Addressing racism in the health-care system through initiatives such as mandatory cultural safety training for health-care providers;
• Prioritizing the training and hiring of First Nation health-care professionals;
• Further development of First Nation health research partnerships;
• Improving access to health care designed and delivered through First Nation-led partnerships.

The full study is available online.