Developing injury indicators for First Nations and Inuit children and youth in Canada: a modified Delphi approach - CDIC: Vol 34, No 4, November 2014

Volume 34 · Number 4 · November 2014

Developing injury indicators for First Nations and Inuit children and youth in Canada: a modified Delphi approach

I. Pike, PhD (1, 2, 3); R. J. McDonald, PhD (3, 4); S. Piedt, BA (2, 3); A. K. Macpherson, PhD (3, 5)

https://doi.org/10.24095/hpcdp.34.4.03

This article has been peer reviewed.

Author references:

1. Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
2. B.C. Injury Research and Prevention Unit, Child and Family Research Institute, B.C. Children's Hospital, Vancouver, British Columbia, Canada
3. First Nations and Inuit Children and Youth Injury Indicators Working Group^{Endnote *}
4. Katenies Research and Management Services, Akwesasne Mohawk Territory, Cornwall, Ontario, Canada
5. School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Ontario, Canada

Correspondence: Shannon Piedt, B.C. Injury Research and Prevention Unit, F508-4480 Oak Street, Vancouver, BC V6H 3V4; Tel.: 604-875-2000 ext. 5478; Fax: 604-875-3569; Email: spiedt@cw.bc.ca

Abstract

Introduction: The purpose of this research was to take the initial step in developing valid indicators that reflect the injury issues facing First Nations and Inuit children and youth in Canada.

Methods: Using a modified-Delphi process, relevant expert and community stakeholders rated each indicator on its perceived usefulness and ability to prompt action to reduce injury among children and youth in indigenous communities. The Delphi process included 5 phases and resulted in a refined set of 27 indicators.

Results: Indicators related to motorized vehicle collisions, mortality and hospitalization rates were rated the most useful and most likely to prompt action. These were followed by indicators for community injury prevention training and response systems, violent and inflicted injury, burns and falls, and suicide.

Conclusion: The results suggest that a broad-based modified-Delphi process is a practical and appropriate method, within the OCAP™ (Ownership, Control, Access and Possession) principles, for developing a proposed set of indicators for injury prevention activity focused on First Nations and Inuit children and youth. Following additional work to validate and populate the indicators, it is anticipated that communities will utilize them to monitor injury and prompt decisions and action to reduce injuries among children and youth.

Keywords: First Nations, Inuit, indigenous populations, injury indicators, modified-Delphi technique, surveillance

Introduction

Injury has been recognized as an important health problem, one that strikes particularly hard at the most vulnerable people—children, youth, seniors and indigenous populations.^{Endnote 1} Injury is the leading cause of death among Canadian children, youth and young adults—a situation particularly important to indigenous First Nations and Inuit communities as more than 50% of their populations are under 25 years of age.

Injury is by far the greatest source of potential years of life lost (PYLL) among First Nations^{Endnote **} populations. At almost 3.5 times the national average, injury accounts for 26% of deaths among First Nations, compared with 6% of deaths overall in Canada.^{Endnote 2, Endnote 3} The injury rates among indigenous teens are almost 4 times greater than those of non-indigenous Canadians, and First Nations male and female youth are, respectively, 5 to 7 times more likely to die of suicide than their peers in other populations.^{Endnote 1, Endnote 4} Hospitalization rates due to injury are also significantly higher (twice the rate) for children and youth living in areas with a high percentage of indigenous residents compared to those living in areas with a low percentage of indigenous residents.^{Endnote 5}

To begin to address these injury disparities, respectful approaches that are collaborative, sustainable and culturally sensitive and that reflect the unique identities of First Nations and Inuit peoples are recommended. ^{Endnote 2, Endnote 6} In 2004, the Canadian Child and Youth Health Coalition listed injury prevention/trauma as one of the theme areas to establish Canadian infant, child and youth health indicators.^{Endnote 7} Despite this, Canada had fallen behind comparable countries in many of the key health indicators for children and youth.^{Endnote 8} A 5-year injury prevention strategic plan indicated the need to identify injury prevention programs and strategies within Inuit communities and establish an integrated surveillance system to measure injury trends.^{Endnote 9} And, while the First Nations Regional Longitudinal Health Survey gathers valuable individual and community information in Canada, some of which is focused on injury, no systematic gathering of comprehensive injury information currently takes place across the country for First Nations children and youth.

The purpose of this research was to take the initial step to develop valid indicators reflective of the injury issues facing First Nations and Inuit children and youth in Canada. The research builds upon the initial work of the Canadian Injury Indicators Development Team, a group of national injury prevention researchers, practitioners and policy makers who established national injury indicators for Canadian children and youth.^{Endnote 10} Cryer^{Endnote 11,p.3-1} defined an injury indicator as "…a summary measure which denotes or reflects, directly or indirectly, variations and trends in injury, or injury-related or an injury control-related phenomenon." The specific aims of our present study were:

1. to develop a strong collaborative working group of individuals and agencies representing indigenous peoples, and
2. to develop and specify a suite of valid indicators that can provide a baseline for First Nations and Inuit communities to document, analyze and report child and youth injury data.

Once the indicators are populated with data, the resulting information can be used to support community injury prevention decision-making and action planning. Tracked over time, these indicators can show how a community or group's injury profile has changed.^{Endnote 12}

An indicator is valid when itmeasures what it is presumed to measure.^{Endnote 13} The indicators in this study were developed based upon the work of the International Collaborative Effort on Injury Statistics (ICE)^{Endnote 11} in 2001 and subsequent work by Cryer et al.^{Endnote 14} that outlined criteria for indicator validity. These criteria suggest that an ideal indicator for injury cases should

• have a case definition based on diagnosis–on anatomical or physiological damage;
• focus on serious injury;
• have, as far as possible, unbiased case ascertainment;
• be derived from data that are representative of the target population;
• be based on existing data systems (or it should be practical to develop new data systems that would feed into it); and
• be fully specified in writing.

Methods

In early 2007, the First Nations and Inuit Health Branch, Health Canada invited the Canadian Injury Indicators Team to begin a 3-year project to develop injury indicators for First Nations and Inuit children and youth. In Canada, First Nations and Inuit peoples are represented by many local, regional and national indigenous agencies as well as the federal government departments whose responsibility it is to ensure the provision of health and social programs, including initiatives to reduce injury.

From the outset, the process and methods of this project sought to balance scientific rigour and a community-oriented approach consistent with the OCAP™ principles underlying the collection of indigenous peoples' data and information in Canada. That is, the data are Owned, Controlled, Accessed and Possessed by the indigenous community.^{Endnote 15} Briefly, the process attempted to ensure a practical approach to injury indicator development.

The First Nations and Inuit Health Branch, Health Canada identified relevant participants in this research and therefore included representatives from the Assembly of First Nations, Inuit Tapiriit Kanatami, Royal Canadian Mounted Police, Indian and Northern Affairs Canada, the SMARTRISK Foundation, Children's Hospital of Eastern Ontario, Plan-It-Safe Program, Katenies Research and Management Services, Statistics Canada, Nunatsiavut Department of Health and Social Development and Pauktuutit Inuit Women of Canada. Twenty-one participants from these agencies came together to plan the project and commence the process; together they formed the First Nations and Inuit Child and Youth Injury Indicators Project Working Group.

A multi-phase modified-Delphi research design was adapted from the methods described by Lindsay et al.^{Endnote 16} and applied to the development of injury indicators for First Nations and Inuit children and youth. The choice of each indicator was based on limited available data and information describing the burden of injury on First Nations and Inuit children and youth, previous prevention research and best practices and ongoing input from expert Working Group members and their respective networks.

Phase I: Literature review

Phase I included a review of the relevant literature, with the goal of identifying any previously established valid and evidence based First Nations and Inuit child and youth injury indicators. Research analysts at the First Nations and Inuit Health Branch, Health Canada conducted the literature review based upon the methodology used by Pike et al.^{Endnote 10} using the following databases for the period 1985 to 2007, inclusive: Medline, Ovid, Transport, Transportation Research Information Services, Sportdiscus, Cumulative Index to Nursing and Allied Health Literature, Embase, Psychinfo, Healthstar and Hispanic American Periodicals Index. The search also included indigenous agency and government websites and program report listings as a means of accessing relevant grey literature. The research analysts identified and summarized a total of 10 studies from the peer-reviewed and grey literature (list available from the authors upon request). The review of literature revealed an initial list of 48 injury indicators.

Phase II: Establishing important injury categories and ranking injury indicators

Of the 21-member Working Group, 19 were able to meet and agree on 4 areas in which to group child and youth injury indicators relevant to First Nations and Inuit communities: workplace, home and public safety; transport; sport and recreation; and inflicted injury / violence (including self-inflicted injury). Using their expertise, personal experience and knowledge of the research, the group discussed the most common injuries within each area and a way to potentially measure and monitor those injuries. As a result, 4 types of indicators were defined and described: outcome, risk and protective factors, program and policy.

The group then divided into small groups based on the 4 injury areas and reviewed the 48 indicators suggested by the literature review, adding additional indicators where deemed appropriate. Following full review and discussion, each small group presented their list of indicators to the large group. All in all, the list included 170 indicators.

With the goal of reducing the number of indicators while retaining those considered important and reflective of the community child and youth injury issues, the Working Group undertook another exercise to prioritize the indicators. In this exercise, the list of indicators was posted on flip charts. Participants were each given 55 paper adhesive dots (approximately one-third the number of the posted indicators) and instructed to position these beside those indicators they considered the most important. All indicators that were marked with 10 or more dots (representing an initial indication of importance) were retained and the remainder rejected. This N/3 technique of prioritizingEndnote 17 resulted in a list of 62 indicators that were regrouped by the participants from the original 4 into 7 broad injury categories: all injury areas; animal bites and hypothermia / frostbite; violent/inflicted injury; burns and falls; drowning; suicide; and motorized vehicle collisions.

The criteria used to inform priority setting included choosing injury indicators that

1. reflected a significant burden to First Nations and Inuit peoples, their families and the health care system, and
2. could be acted upon through prevention initiatives.

Further, the participants were provided the International Collaborative Effort Injury Indicators Group (ICEIInG) criteria for indicator validity to inform their decision-making.

The subsequent step was to review and further refine the list of 62 indicators. Working Group members were asked to consult with their constituent groups and, for each indicator, recommend whether to "keep" or "let go" of it or whether they were "unsure" based upon 3 criterion questions:

1. Is this indicator important in your community?
2. Would this indicator help you to track injuries in your community?
3. Does this indicator give you sufficient information to take action to prevent injuries among children and youth in your community?

We reviewed the responses and retained those indicators that a majority of the Working Group had recommended keeping. Indicators that received a majority of "let go" responses were dropped. (No indicators received a majority vote of "unsure."') During this phase of the process and as a result of discussion among themselves, Working Group members proposed 2 additional indicators, which were circulated and judged to be important enough to keep: the percentage of children/ youth enrolled in "learn to swim" programs and percentage of violent offenders participating in restorative justice programs were included as additional potential indicators, resulting in a list of 36 injury indicators at this stage.

Phase III: Regional feedback

Further input was sought from potential users at the community level. Investigators attended regional meetings and engaged First Nations and Inuit injury prevention practitioners and decision makers. At each meeting, the project was explained and participants were asked for their feedback on the list of 36 child and youth injury indicators.

Feedback on each injury indicator was obtained from a number of regional organizations in Alberta, Manitoba, Ontario, Quebec and Nunatsiavuut: the Manitoba Community Wellness Working Group, the Assembly of First Nations Regional Injury Prevention Working Group, the First Nations Early Childhood Circle (representatives from Saskatchewan Aboriginal Head Start Initiative and Federation of Saskatchewan Indian Nations), Chiefs of Ontario and the National Inuit Council on Health.

In this phase of the process, regional agency representatives identified 7 additional indicators judged to be important in understanding and preventing child and youth injury in their communities. As a consequence, the list of potential injury indicators increased from 36 to 43.

Phase IV: Specification of indicators

We created a standard template for indicator specification (see Table 1) and developed draft specifications for the 43 indicators based upon the format for previous reports from Australia,^{Endnote 18} New Zealand,^{Endnote 19} Europe^{Endnote 20} and Canada.^{Endnote 21}

The Working Group then met to discuss, revise and refine the indicators and their specifications, and an additional round of review and further feedback was accomplished via email. Nine members of the Working Group responded^{Endnote †} and recommended that several indicators be dropped due to the lack of available data and the difficulty and cost associated with generating new data collection systems to populate those indicators. Phase IV resulted in a further refined list of 33 candidate injury indicators (see Table 2).

Phase V: Finalizing injury indicators

Following the specification of all 33 indicators, the Working Group met for the last time in December 2008 with 13 members attending. Each indicator was rated for perceived usefulness and ability to prompt action to reduce injuries among First Nations and Inuit children and youth using a 9-point scale,with 1 being low (not useful, not actionable) and 9 being high (very useful, very actionable). This resulted in 7 indicators being judged as neither useful nor actionable (and therefore not meeting the criteria for validity), either because of lack of data and/or resources availability, and were dropped (see the shaded indicators in Table 2). The process concluded with the Working Group endorsing a final list of 27 injury indicators for First Nations and Inuit children and youth.

Immediately following the rating process, the group unanimously agreed to re-insert PYLL due to injury, which had been listed at the review of literature stage, although they did not rate it.

Results

The modified-Delphi method resulted in a proposed list of 27 injury indicators. Indicators related to motorized vehicle collisions, mortality rates and the number of children and youth hospitalized due to each injury type ranked highest in terms of usefulness and ability to prompt action. These were followed by community injury prevention training and response systems, violent and inflicted injury, burns and falls, and suicide although some were rated somewhat lower in terms of their ability to prompt action.

Discussion

This modified-Delphi approach represents the first step in the indicator development process that resulted in a final proposed set of 27 First Nations and Inuit child and youth injury-related indicators that can be used to inform injury prevention in Canada's indigenous peoples. While there was some variation in the degree to which experts rated the usefulness and likelihood to prompt action of each indicator, there was general consistency and agreement. The high scores given to the injury indicators suggest that they capture the needs of those working to prevent injuries among First Nations and Inuit children and youth.

While the indicators were developed to apply to First Nations and Inuit children and youth, some indicators are applicable to any children and youth living in rural or remote communities, and others apply to all children and youth.

Strengths and limitations

There are some limitations to this work, which are important to highlight here.

First, there is a paucity of published literature related to indigenous child and youth injury prevention to inform the decision-making around the indicator selection.

Second, the modified-Delphi process technique used is subjective and based upon participant expertise and experience. While efforts to be objective in generating and prioritizing indicators were made within the process, the results depend upon the opinions of the participating experts. Participants were advised of the criteria for indicator validity, but it is not known how much that influenced their choice of indicators. It is possible that the results would be different had a different group of experts participated. However, the experts chosen were those deemed most relevant to the process because they were knowledgeable about the field and the best representatives of their agencies and constituents.

A further limitation is the current and continuing lack of the data necessary to populate the indicators. Some indicators had no data available, and may not have in the foreseeable future. However, data for many of the indicators are available from the First Nations Regional Longitudinal Health Survey, and some communities (e.g. 10 bands of the Secwepemc Nation in British Columbia) collect health and injury data that can populate the indicators. In addition, we anticipate that, with time, more communities will gather their own data and information of local interest and relevance to child and youth injury prevention. This approach is consistent with the OCAP™ principles.^{Endnote 15}

Conclusion

Using a systematic, interdisciplinary modified-Delphi method, which involved direct input and leadership from First Nations and Inuit experts, this study resulted in a proposed list of 27 useful and actionable injury indicators to guide First Nations and Inuit community injury prevention initiatives focused on children and youth.

While several of the indicators are in line with those developed for non-indigenous Canadian children and youth,^{Endnote 10} differences do exist. Most important, the current indicators are specific to injury among First Nations and Inuit children and youth, reflecting local circumstances and conditions important to injury risk and prevention in indigenous communities, some of which are small, rural and remote. For example, the First Nations and Inuit indicators included those that relate to community injury prevention training and response systems, animal bites, drowning, hypothermia and frostbite, which were considered less important for non-indigenous populations.

Further research and collaboration by the Working Group with indigenous communities will demonstrate the utility of the indicators in furthering injury prevention. Work will continue to identify the necessary appropriate data and information to populate the indicators. It is anticipated that the research team will work with communities to gather the necessary data and information to populate the indicators, including helping develop consistent definitions of causes of injury and injury severity. Ultimately, indigenous health authorities and communities can use the information to plan, implement and evaluate programs and initiatives to prevent injury among children and youth, consistent with the OCAP™ principles underlying research among Canadian indigenous communities.

Acknowledgments

Funding for this study was provided by the First Nations and Inuit Health Branch at Health Canada (FNIHB), the BC Child and Youth Health Research Network (CYHRNet) and the Canadian Institutes of Health Research (KTB-109190).

The authors wish to acknowledge all members of the First Nations and Inuit Child and Youth Injury Indicators Working Group for their contribution to this research. We would like to acknowledge the First Nations and Inuit Health Branch, Health Canada (FNIHB) and the BC Child and Youth Health Research Network (CYHRNet) for providing the funds to conduct this study and for their support in ensuring timely access to essential resources. In addition, we wish to thank the Assembly of First Nations (AFN), Inuit Tapiriit Kanatami (ITK), Pauktuutit Inuit Women of Canada and the Canadian Institutes of Health Research. We are most grateful to these organizations for the important resources provided and for their ongoing support to facilitate the process of refining our final list of indicators. We also wish to thank the Manitoba Community Wellness Working Group, the AFN First Nations Regional Injury Prevention Working Group, the First Nations Early Childhood Circle (representatives from the Saskatchewan Aboriginal Head Start Initiative and Federation of Saskatchewan Indian Nations), the Chiefs in Ontario, the AFN Health Officers Council, the representatives of the First Nations Regional Longitudinal Health Survey and the National Inuit Committee on Health for their input during the process of determining and refining the list of indicators.

References

Appendix

Injury Indicators for First Nations and Inuit Children and Youth Specification Details for Injury Indicators

Introduction

First Nations and Inuit children and youth experience a significantly higher rate of injury-related death and disability than other young people in Canada. An accurate determination of the factors related to injury as well as the ability to monitor trends and patterns among First Nations and Inuit children and youth is desirable to assist with prevention. Building upon previous work by the Canadian Injury Indicators Development Team to establish national injury indicators for Canadian children and youth, the purpose of this research was to take the initial step to develop valid indicators reflective of the injury issues facing First Nations and Inuit children and youth in Canada.

The specific aims of the present study were

1. to develop a strong collaborative working group of individuals and agencies representing indigenous peoples, and
2. to develop and specify a suite of valid indicators that can provide a baseline for First Nations and Inuit communities to document, analyze and report child and youth injury data.

The collaborators in this project committed to follow principles and ethics reflecting indigenous research in Canada. Specifically, the First Nations OCAP™ principles of Ownership, Control, Access, and Possession of Indigenous data, information and knowledge.

Once the indicators are populated with data, the resulting information can be used to support community injury prevention decision making and action planning; tracked over time, these indicators can tell a story of how a community or group's injury profile has changed. As such, this specification document represents a draft document that will be updated as indicators are populated and utilized.

The Process

In early 2007, the Canadian Injury Indicators Team was invited by the First Nations and Inuit Health Branch, Health Canada to begin a 3-year project to develop injury indicators for First Nations and Inuit children and youth. In Canada, First Nations and Inuit peoples are represented by many local, regional and national indigenous agencies as well as departments of the Federal Government whose responsibility it is to ensure health and social programs including initiatives to reduce injury are provided. Relevant participants in this research were identified by the First Nations and Inuit Health Branch (FNIHB), Health Canada, and included representatives from the Assembly of First Nations, Inuit Tapiriit Kanatami, Royal Canadian Mounted Police, Indian and Northern Affairs Canada, the SMARTRISK Foundation, Children's Hospital of Eastern Ontario, Plan-It-Safe Program, Katenies Research and Management Services, Statistics Canada, Nunatsiavut Department of Health and Social Development, and Pauktuutit Inuit Women of Canada. Twenty-one participants from these agencies came together to plan the project and commence the process. Together, they formed the First Nations and Inuit Child and Youth Injury Indicators Project Task Group.

Using a modified-Delphi process, this research first developed valid indicators reflective of the injury issues facing First Nations and Inuit children and youth in Canada. Relevant expert and community stakeholders rated each indicator on its importance to their community to:

1. assist in monitoring injuries, and
2. its usefulness and
3. its ability to prompt action to reduce injury.

From an initial list of 48 indicators based upon a literature review, a refined set of 27 indicators was established. Indicators related to motorized vehicle collisions, mortality and hospitalization rates were rated the most useful and most likely to prompt action. These were followed by community injury prevention training and response systems, violent and inflicted injury, burns and falls, and suicide indicators. Following additional work to populate the indicators, it is anticipated that communities will utilize them to monitor injury and prompt decisions and action to reduce injuries among children and youth.

To ensure a standard approach to populating and utilizing the injury indicators, this document details how best to use the information as a community injury prevention resource and provides the detailed specification of each indicator.

How to Use This Document

It is intended that the indicators listed in this document will help to identify the burden of indigenous child and youth injuries on families, communities and regions so that decision and action to prevent injuries is prompted. The statistics in this document make it clear that more needs to be done to promote/improve injury prevention efforts for all children and youth.

Community leaders and community members can use the indictors to

• identify trends and patterns in injury in the community so that injury prevention resources can be targeted where most needed
• gather statistical data to support a request for further injury prevention resources
• evaluate the impact of injury prevention interventions

Regional leaders, researchers or policy makers can use the indicators to

• identify trends and patterns in injury for a whole region so that injury prevention resources can be targeted where most needed
• compare injury outcomes between communities with the goal to identify community-specific best practices in injury prevention
• evaluate the impact of injury prevention interventions

Commonly Used Terms in This Document

The First Nations Regional Longitudinal Health Survey (RHS) is a national survey that produces health and social data for on-reserve First Nations communities (on-reserve) across the country. It is conducted across the 10 regions in Canada, surveying participants in over 200 First Nation communities. The First Nations Information Governance Centre provides oversight to the RHS.

The RHS is a source of First Nations data for many of the indicators, using 4 survey components:

• Adult (≥18 years, self-reported)
• Youth (12–17 years, self-reported)
• Child (0–11 years, completed by primary care giver)
• Community Survey

The Aboriginal Peoples Survey (APS) is a National Survey of First Nations, Inuit and Métis people in Canada (Statistics Canada, 2007), conducted by Statistics Canada.

The Canadian Community Health Survey (CCHS) is conducted by Statistics Canada and collects information from over 130 000 respondents, aged 12 years or older, residing in households across all provinces and territories. The survey includes a section on injuries (Statistics Canada, 2005). Profiles are presented by a series of variables by different geographies, such as health regions, census metropolitan areas and rural/urban groups. CCHS has a profile for Aboriginals, but does not specify First Nations or Inuit.

International Classification of Disease Codes (ICD-10) is a coding system used to classify diseases and other health problems recorded on many types of health and vital records including death certificates and hospital records. In addition to enabling the storage and retrieval of diagnostic information for clinical and epidemiological purposes, these records also provide the basis for the compilation of national mortality and morbidity statistics by WHO Member States (World Health Organization, 2008). This document uses the term ICD-10-CA, which refers to version 10 in Canada.

Advocacy: For the purposes of this document, advocacy may include promoting and encouraging behaviour change, local interventions and seeking support at all levels of government and from non-government organizations (NGOs).

Injury Indicator Specifications Tables

The purpose of the Injury Indicator Specification Tables that follow is to clearly define and specify each of the 27 indigenous child and youth injury indicators. These tables are intended to provide community injury prevention leaders and practitioners, policy makers and non-governmental organizations with greater understanding of the indicators and their application in a consistent manner.

The detailed injury Indicator Specification Tables provide information on the key components of each indicator, including:

• A clear definition of the indicator itself, as well as definitions of important key terms
• Inclusion and/or exclusion criteria
• The underlying rationale for each indicator, including why it is important, what it means and how it should be interpreted.

It should be noted, however, that although each indicator is defined and specified, not all of the suggested or required data and/or information are available in Canada at this time. Utilization of the indicators and future research will serve to demonstrate the utility of these indicators to further injury prevention research, policy and practice.

In essence, it is hoped that these Indicator Specification Tables will encourage community practitioners, in particular, to think about the data and information they gather in their own communities, allow them to monitor their own local injury prevention systems and enable them to develop new local injury prevention initiatives based on what they learn.

Injury Indicator Specifications Table Attributes

The Indicator Specification Tables describe a number of attributes for each indicator. The diagram below numbers each individual attribute and is followed by corresponding definitions.

1. Type of Indicator: Indicators are classified using 3 types of indicators.
   • Community Training and Capacity – captures data regarding injury prevention training and capacity currently in place. Further work is needed to reflect the degree to which best practice is reflected within training and capacity-building programs.
   • Risk / Protective Factor – captures data regarding the use or non-use of protective equipment. Child restraint use, seatbelt use, helmet use are all examples of risk indicators.
   • Outcome – captures the sequelae of injuries. The number of children and youth who die or who are injured and the causes of those injuries give us a picture of the burden of injury in indigenous communities in Canada.
2. Indicator Domain: Indicators are grouped in 9 domains, based upon the burden of injury and the collective expertise of the expert team. The Indicator Specification Tables are organized by domain, in the following order:
   • Across All Injury Areas
   • Community Injury Prevention Training / Response Systems
   • Animal Bites
   • Hypothermia/Frostbite
   • Violent / Inflicted Injury
   • Burns and Falls
   • Drowning
   • Suicide / Self-Harm
   • Motorized Vehicle Collisions
3. Indicator Number and Title: Each indicator is identified by a title and a number, assigned sequentially.
4. Indicator Definition: Provides a concise definition of the specific aspects that the indicator addresses.
5. Definition of Relevant Terms: Provides a definition for the relevant technical terms used within the indicator definition or description.
6. Justification for this Indicator: Explains the importance and relevance of the indicator to indigenous community child and youth injury prevention.
7. What are we Counting? Definition of a case.
8. Where do we obtain data / information for this indicator? Identifies data sources that can be used to calculate the indicator.
9. What data do we need? Specific description of the data required for the indicator.
10. Method of Calculation: Provides a method of calculation and, for rate-based indicators, provides the description of the general specifications of any component that is the basis for inclusions and exclusions in the numerator and denominator needed to calculate it.
11. Numerator: Used in calculation.
12. Denominator: Used in calculation.
13. Limitations: Identifies limitations specific to each indicator.

Indicators

Recommendations

After completing the work within this document, there are 3 recommendations that stand out:

1. A survey similar to the First Nations Regional Longitudinal Health Survey needs to be created for/with Inuit communities. The lack of Inuit data makes it very difficult to populate these indicators with information that is relevant to Inuit communities. Inuit-specific data is needed in order to properly assess the injury problem for Inuit children and youth.
2. Community-level surveillance to gather specific data points would do much to address the gaps in data identified in this document. It is recommended that communities facilitate community-level surveillance whenever possible.
3. These indicators need to be populated with data. In order to ensure that the burden of injury decreases, work is needed to illuminate these indicators with data and make a plan for indicator uptake. The information gleaned through the use of these indicators will facilitate improved decision making and action to decrease injuries among indigenous children and youth in Canada.

References

Canadian Public Health Association. (2006). Pot and Driving in the North. Ottawa: Canadian Public Health Association.

Chandler, M.J., & Lalonde, C.E. (1998). Cultural continuity as a hedge against suicide in Canada's First Nations. Transcultural Psychiatry, 35(2), 191-219.

Cryer, C., Langley, J., and Stephenson, S. (2004). Developing Valid Injury Outcome Indicators. Dunedin: New Zealand Injury Prevention Strategy.

Cryer, C., Langley, J.D., Stephensen, S.C., Jarvis, S.N., & Edwards, P. (2002). Measure for measure: the quest for valid indicators of non-fatal injury incidence.
Public Health. Sep, 116(5), 257-62.

First Nations Centre (2005). First Nations Regional Longitudinal Health Survey (RHS) 2002/03. Ottawa: First Nations Centre.

Health Canada.(1997). Economic Burden of Illness in Canada, 1993. Ottawa: Minister of Public Works and Government Services Canada.

Leblanc, J.C., Beattie, T.L., Culligan, C. (2002). Effect of legislation on the use of bicycle helmets. CMAJ Canadian Medical Association Journal, 166, 592-5.

McDonald, Rose-Alma J. (2006). An AFN Handbook for Injury Prevention for First Nation Communities. Ottawa: Assembly of First Nations.

McDonald, Rose-Alma J. (2006). Injury Prevention Fact Sheets. Ottawa: Assembly of First Nations.

Plourde, C. et al. Use of alcohol and other drugs by Nunavik youths: key results of the survey. Recherche et intervention sur les substances psychoactives – Québec. 2007. (leaflet and presentation)

Public Health Agency of Canada. (2005). Inventory of Injury Data Sources and Surveillance Activities. Ottawa, Ontario: Minister of Health Canada and the Minister of State for Public Health.

Simpson, H. (2003). The Evolution and Effectiveness of Graduated Licensing. Journal of Safety Research 34(1), 25-34.

World Health Organization. (1992). International statistical classification of diseases and related health problems. 10th revision. Geneva: WHO.

Online References

Assembly of First Nations (2006). Fire. Injury Prevention Fact Sheet. Retrieved on September 3, 2014,

FEI Behavioral Health (2007). Crisis Management Disaster Communication Plan. Retrieved on August 27, 2007

Section 1.01 First Nations Information Governance Centre. Accessed on August 19, 2013.

Section 1.02 George, Jane. (2007, September 14). ATVs take toll on Nunavik youth. Nunatsiaq News. Retrieved on Dec. 6, 2007.

Health Canada (2006). It's your Health: Smoke Detectors. Retrieved on August 24, 2007

Health Canada (2005). Unintentional and Intentional Injury Profile for Aboriginal People in Canada. Retrieved on November 23, 2007

Indian and Northern Affairs Canada (2004). Backgrounder The Proposed Westbank First Nation Self-Government Act. Retrieved August 20, 2007.

Industrial Accident Prevention Association (2006). Fire Distinguishers. Retrieved on Aug 24, 2007.

McFarlane, P. (1997, Winter). New approaches to injury prevention. In Touch. 7 (3). Retrieved on September 3, 2014.

Merriam-Webster Dictionary (2007). Definition of substance. Retrieved on August 8, 2007.

Merriam-Webster Dictionary (2007). Definition of Drug. Retrieved on August 9, 2007.

Merriam-Webster Dictionary (2007). Definition of Mauling. Retrieved on November 30, 2007.

Medline Plus (2007). Definition of incidence. Retrieved on August 8, 2007

Supporting First Nations, Inuit and Métis People in Addressing Their Needs. (2006). Retrieved on August 10, 2007

National Indian & Inuit Community Health Representatives Organization (2007). In Touch Winter 7(3).

Public Health Agency of Canada (2005). Child Abuse and Neglect Overview Paper. Retrieved on November 15, 2007.

Royal Canadian Mounted Police (2007). Deal.org Domestic Abuse. Retrieved on Aug 8, 2007.

Royal Canadian Mounted Police (2007). Community, Contract, and Aboriginal Policing. Retrieved on Nov 27, 2007.

Sexual Exploitation (2005). Retrieved on November 15, 2007.

Statistics Canada (2007). Aboriginal Children's Survey. Retrieved on September 20, 2007.

Statistics Canada (2005). Canadian Community Health Centre Profiles. Retrieved on October 31, 2007.

The New York Times Company (2007). Survive the unthinkable through crisis planning. Retrieved on Aug 27, 2007.

Transport Canada (2005). Road Safety Vision 2010: Making Canada's Roads the Safest in the World. Retrieved on March 6, 2007.

U.S. National Fire Protection Association (2007). Smoke Alarms. Retrieved on November 28, 2007

U.S. National Fire Protection Association (2007). Fire Extinguishers. Retrieved on November 28, 2007.

Wikipedia (2008). Carbon Monoxide Detector. Retrieved on December 22, 2008

Wikipedia (2013). Search and Rescue. Retrieved on September 30, 2013

World Health Organization (2008). International Classification of Diseases. Retrieved on January 16, 2008.

World Health Organization (2007). Substance Abuse. Retrieved on Aug 8, 2007.

Younger-Lewis, Greg. (2004, January 23). Assault, property crime up in Iqaluit in 2003. Nunatsiaq News. Retrieved on Dec. 6, 2007.