"You can feel the fresh air … " Rural Alaska Native household perceptions of home air purifiers and health

Alaska Native and American Indian children experience frequent respiratory illness. Indoor air quality is associated with the severity and frequency of respiratory infections in children. High efficiency particulate air (HEPA) purifiers effectively improve indoor air quality and may protect respiratory health. In 2019, the Yukon-Kuskokwim Health Corporation implemented a pilot programme that provided education and HEPA purifiers to households of children with chronic lung conditions. The team evaluated HEPA purifier acceptability and use by interviewing representatives from 11 households that participated in the pilot programme. All interviewees reported improvement in their child's health, and some believed that the health of other household members was also improved because of the HEPA purifier. Interviewees reported that the HEPA purifiers were easy to use, quiet, and not expensive to run. Five of 11 households were still using the HEPA purifier at the time of the interview, which was about three years after receipt of the unit. The most common reasons for discontinuing use were equipment failure and lack of replacement filter, suggesting that programme support could increase sustainability. Our evaluation suggests that HEPA purifiers are acceptable and feasible for use in rural Alaska Native households.

Urgent versus elective surgical disparities among American Indian and Alaska Native patients

BACKGROUND

American Indian and Alaska Native (AIAN) health issues are understudied despite documentation of lower-than-average life expectancy. Urgent surgery is associated with higher rates of postsurgical complications and postoperative death. We assess whether American Indian and Alaska Native (AIAN) patients in Washington State are at greater risk of requiring urgent rather than elective surgery compared with non-Hispanic Whites (NHW).

METHODS

We accessed data for the period 2009-2014 from the Washington State Comprehensive Hospital Abstract Reporting System (CHARS) database, which captures all statewide hospital admissions, to examine three common surgeries that are performed both urgently and electively: hip replacements, aortic valve replacements, and spinal fusions. We extracted patient race, age, insurance status, comorbidity, admission type, and procedures performed. We then constructed multivariable logistic regression models to identify factors associated with use of urgent surgical care.

RESULTS

AIAN patients had lower mean age at surgery for all three surgeries compared with NHW patients. AIAN patients were at higher risk for urgent surgery for hip replacements (OR = 1.49, 95% CI 1.19-1.88), spinal fusions (OR = 1.39, 95% CI 1.04-1.87), and aortic valve replacements (OR = 2.06, 95% CI 1.12-3.80).

CONCLUSION

AIAN patients were more likely to undergo urgent hip replacement, spinal fusion, and aortic valve replacement than NHW patients. AIAN patients underwent urgent surgery at younger ages. Medicaid insurance conferred higher risks for urgent surgery across all surgeries studied. Further research is warranted to more clearly identify the factors contributing to disparities among AIAN patients undergoing urgent surgery.

Oncology Nurse Navigation in Underserved Communities: Opportunities and Future Directions

OBJECTIVES

Provide an overview of navigation in three disparate populations: rural, Native American/Alaska Native, and low- to middle-income countries. Discuss gaps in care and opportunities to improve cancer care.

METHODS

A literature search was conducted in PubMed and on Google Scholar using search terms, nurse navigation, cancer, disparit*, low- to middle-income countries, Native American, American Indian, and rural. Peer-reviewed research studies, review articles, databases and websites of professional organizations, and historical books were reviewed to provide an overview of oncology nurse navigation in underserved communities. Experiences in working with these populations over the past 30 years were also provided to support current literature.

RESULTS

Forty references were included in this overview of nurse navigation in underserved communities. Nurse navigation in these disparate areas is in its infancy. While some programs exist and outcomes have been positive, their dissemination is sparse. A need exists to expand nurse navigation into these areas to provide care for these underserved communities.

CONCLUSION

Oncology nursing navigation for each of these underserved communities requires a culturally sensitive approach. Many of these approaches are universal to cultural competency and can be applied to most disparate populations.

IMPLICATIONS FOR NURSING PRACTICE

Nurses comprise the largest workforce around the globe and are well-equipped to develop navigation programs in some of the most disparate communities around the world. To do so, it is important to use a foundation of building trust, embracing individual differences, providing culturally sensitive education and resources for growth, and good communication.

Persistent cervical cancer disparities among American Indian/Alaska Native women: a systematic scoping review exploring the state of the science in this population

PURPOSE

American Indian/Alaska Native (AI/AN) populations experience significantly higher incidence and mortality rates of cervical cancer. The objective of this systematic scoping review is to characterize the volume and nature of research being conducted specific to the AI/AN population regarding cervical cancer and related clinical themes.

METHODS

This scoping review was conducted in collaboration with the Pacific Northwest Evidence-based Practice Center. Search strategies identified eligible publications from 1990 through 4 February 2022. Two reviewers independently abstracted study data, including clinical area, number of participants and percent inclusion of AI/AN, intervention or risk factor, outcomes reported, Indian Health Service (IHS) Region, and funding source. We used published algorithms to assess study design.

RESULTS

Database searches identified 300 unique citations. After full-text evaluation of 129 articles, 78 studies and 9 secondary publications were included (total of 87). Approximately 74% of studies were observational in design, with cross-sectional methodology accounting for 42.7% of all included studies. The most common clinical theme was cervical cancer screening. The most common intervention/exposure was risk factor, typically race (AI/AN compared with other groups) (69%). For studies with documented funding sources, 67% were funded by the US Government.

CONCLUSION

Of the small number of publications identified, the majority are funded through government agencies, are descriptive and/or cross-sectional studies that are hypothesis generating in nature, and fail to represent the diversity of the AI/AN populations in the US. This systematic scoping review highlights the paucity of rigorous research being conducted in a population suffering from a greater burden of disease.

Because We Love You (BeWeL): A protocol for a randomized controlled trial of two brief interventions focused on social and cultural connectedness to reduce risk for suicide and substance misuse in young Alaska Native people

Background

Suicide among young people in Alaska Native (AN) communities was nearly unheard of through the establishment of statehood in 1959, but in the 1970s, AN suicide rates began to double every five years, with most of the increase due to suicide among 15 to 25-year-olds. From 1960-1995, the suicide rate increased by approximately 500% during this period of rapid, imposed social transition. For example, families were forced to live in settlements and children were sent to boarding schools. These disruptions increased conditions associated with suicide risk (e.g., substance use disorders, cultural disconnection), and challenged the community-level social safety net of youth protective factors that might have moderated effects of these traumas. The present study addresses the significant gap in culturally appropriate evidence-based programming to address suicide prevention among AN young people as part of aftercare. Our key research questions and methodology have been informed by AN stakeholders, and the intervention approach is Indigenous-led.

Methods

Our interventions are targeted toward Alaska Native young people ages 14-24 who present with suicide attempt, ideation, or associated risk behaviors, including alcohol-related injury in the Yukon-Kuskokwim region or the Interior. In a randomized controlled trial, 14-24-year-old AN individuals will receive either BeWeL (n = 185), which comprises a 45-minute virtual cultural talk addressing family and ancestral strengths and increasing protective factors, or BeWeL plus motivational interviewing with social networks, which includes an additional 15 minutes focused on discussion of the individual's social networks (n = 185). We will evaluate intervention effects on primary outcomes of suicide-intent risk, depression, anxiety, frequency of alcohol use, and alcohol consequences. Some of our secondary outcomes include individual and community protective factors, social networks, and awareness of connectedness.

Discussion

This project has the potential to expand the range and effectiveness of suicide prevention services for AN young people and will help meet the need in Alaska to link clinical behavioral health services to AN community-based networks, and to engage local cultural resources in aftercare for individuals at risk for suicide. Findings have potential to provide practical information to advance the field of suicide prevention and enhance protective factors and resiliency among this population.

Trial registration

ClinicalTrials.gov Identifier: NCT05360888.

The criminal justice system in alcohol use treatment: a nationwide analysis of racial disparities in treatment referral and completion

BACKGROUND

Alcohol use and the criminal justice (CJ) system have long been integrally connected in the United States and have both disproportionally impacted Communities of Color. Despite this connection, scholarly literature has largely focused on substance use as a whole, and little literature has examined the influence of race on CJ referral to alcohol treatment and treatment outcomes.

METHODS

A total of 749,349 cases from the treatment episodes dataset discharge were used in the current study. A series of ANOVA and logistic regression analyses were conducted to examine the impact of race on (i) likelihood of referral to alcohol treatment by the CJ system and (ii) the association between CJ referral and treatment completion.

RESULTS

Results revealed significant disparities in both who is referred to alcohol treatment by the CJ system and the association of that referral to treatment completion. Notably, American Indian/Alaska Native people were significantly more likely than people of all other races to be referred by the CJ system. However, American Indian/Alaska Native people showed the smallest association between CJ referral and treatment completion.

CONCLUSIONS

Contrary to previous literature, findings showed that referral of and positive association between CJ referral and treatment completion are not equal across people of different races. Taken together, these results highlight continued racial inequities in the role of the CJ system in alcohol treatment and the unique potential for non-CJ-related treatment to best serve people combatting alcohol use disorder.

Regular aspirin use among a sample of American Indians/Alaskan Natives in the Upper Midwest region of the United States

Despite high prevalence of cardiovascular disease (CVD) and CVD risk factors among American Indian or Alaska Native adults (AI/AN), there is little information on aspirin use in this population. This survey-based study seeks to understand prevalence of aspirin use in a sample of AI/AN adults in the Upper Midwestern United States. In-person and telephone based surveys were conducted querying self-reported CVD and CVD risk factors, aspirin use, and aspirin related discussion with clinicians. A total of 237 AI/AN participants were included: mean age (SD) was 60.8 (8.4) years; 143 (60 %) were women; 59 (25 %) reported CVD history. CVD risk factors were common particularly smoking (37 %) and diabetes (37 %). Aspirin use was much higher among those with CVD (secondary prevention, 76 %) than those without (primary prevention, 33 %). Primary prevention aspirin use was significantly associated with age and all CVD risk factors in unadjusted analyses. After adjustment for demographics and CVD risk factors, only age (aRR 1.13 per 5 years, 95 % CI 1.02, 1.25) and diabetes (aRR 2.44, 95 % CI 1.52, 3.92) remained significantly associated with aspirin. Regardless of CVD status, a higher proportion of those taking aspirin reported a conversation about aspirin with their doctor compared to those not taking aspirin. Among participants with no CVD, those who had such a conversation were 2.6 times more likely to use aspirin than those who did not have a conversation (aRR 2.64, 95 % CI 1.58, 4.44). The findings of this study emphasize the importance of the patient-provider relationship for preventive therapy.

An Updated Narrative Review on the Role of Alcohol Among Indigenous Communities

Purpose of Review

The role of alcohol varies considerably among Indigenous Peoples and is the backdrop of persistent stereotypes despite decades of research. This paper provides an updated narrative review on the alcohol literature among Indigenous communities, highlighting recent studies published since 2017.

Recent Findings

We examined published literature involving alcohol use rates, including abstinence; risk and protective factors; treatment; and recovery, as well as future directions for alcohol prevention and intervention efforts with Indigenous communities.

Summary

Evidence-based alcohol use prevention, intervention, and recovery strategies with Indigenous communities are outlined. Recommendations are provided for researchers, health providers, and public policy advocates to address and better understand alcohol use, treatment, prevention, and recovery among Indigenous Peoples. Specific recommendations include using community-based participatory research strategies and harm reduction approaches to prevent and treat alcohol use problems with Indigenous communities. Future research is needed to elucidate mechanisms of resilience and recovery from Alcohol Use Disorder and possible shifts in perceptions of alcohol use for Indigenous Peoples.

The use of patient navigation to transition detoxification patients to substance use treatment in the Alaska Interior

Objectives

Detoxification clinics manage acute intoxication and withdrawal from alcohol and other drugs. At discharge, patients are referred to treatment, yet many are readmitted to detoxification, creating a "revolving door" of discharges and admissions. This pattern disproportionately affects some groups such as Alaska Native and American Indian (AN/AI) people. The primary goals of this study are to: 1) test the effectiveness of a patient navigation intervention to increase rates of transition to alcohol treatment following detoxification, and 2) prevent readmission to detoxification within 12-months. The secondary goal is a cost-effectiveness and cost-benefit evaluation of patient navigation.

Study design

This randomized controlled comparative effectiveness trial plans to recruit 440 patients (∼70% AN/AI) admitted to alcohol detoxification. We collaborated with Fairbanks Native Association (FNA) to select an appropriate intervention, control condition, and other study-related decisions. Here, we describe intervention development, study design, challenges encountered during implementation, and collaborative processes to identify solutions.

Methods

Participants are equally randomized to the control (one motivational interviewing session) or intervention (one motivational interviewing session plus up to four weeks of patient navigation). The primary outcomes are successful transition to alcohol treatment within 30-days after discharge and detoxification readmission within 12-months. The secondary outcome is health-related quality of life.

Conclusion

Patient navigation is successful in other settings and for other health conditions. It may assist in overcoming barriers to successful transition to substance use treatment and may augment interventions, such as motivational interviewing, that are less resource-intensive but may not be optimally effective by themselves.

ClinicalTrialsgov Identifier

NCT03737864.

Past Cannabis Use, Health-Related Worry, and Beliefs About Perceived Benefits of Cannabis Among American Indians/Alaska Natives

BACKGROUND

Most adults report beliefs that cannabis has at least one benefit (e.g., stress relief, chronic pain management); however, the benefits are not well established. Beliefs about cannabis benefits are associated with the initiation of use, whereas beliefs about the risks of cannabis are protective factors against its use. Little is known about how health-related beliefs impact cannabis use among American Indians/Alaska Natives (AIAN).

PURPOSE

This exploratory study examined beliefs about perceived benefits (i.e., stress relief, pain management) of cannabis, how beliefs vary as a function of use, and associations between health worry and benefits of cannabis among AIAN adults.

METHODS

Participants (n = 182) were on average 41.4 (SD = 16.3) years old, 63.9% female, and identified as AIAN. Participants were asked questions about general demographics, health-related worry and perceptions, and cannabis use. Linear regressions were conducted to examine associations.

RESULTS

Those who used cannabis in the past year were more likely to agree that cannabis relieves stress and less likely to believe that those who use cannabis should be very worried about their health. Participants who agreed that those who use cannabis should be worried about their health were less likely to report beliefs that cannabis relieves stress or helps with chronic pain.

CONCLUSIONS

Our study confirms the role of health-related perceptions and worry about cannabis products with cannabis use among this population that may be at risk for higher cannabis use. Findings may have implications for cannabis policy at the tribal, state, and federal levels and the need for the development of targeted communications about the true health risks of cannabis.

Assessing the Feasibility, Acceptability, and Effectiveness of a Pilot Hepatitis C Screening Program at Food Distribution Sites in Cherokee Nation, Oklahoma

Compared with other racial and ethnic groups in the United States, American Indian and Alaska Native (AI/AN) people experience the highest incidence of acute hepatitis c (HCV). Cherokee Nation Health Services (CNHS) implemented a pilot health screening program from January through May 2019 to assess whether conducting HCV and other preventive health screenings at food distribution sites is a feasible, acceptable, and effective strategy to increase health screening among underserved community members. Data were collected among 340 eligible participants. Most (76%) participants reported being very comfortable receiving health screenings at food distribution sites and that getting screened at food distribution sites is very easy (75.4%). Most (92.1%, n = 313) participants received HCV screening, with 11 (3.5%) individuals testing positive for HCV antibodies. Of the 11 HCV seropositive individuals, six were confirmed to have active HCV infection of which four initiated treatment. Most (55.7%) participants exhibited a body mass index in the obese range, 33.1% exhibited high hemoglobin A1C (> 6.0), 24.5% exhibited high (> 200) cholesterol, 44.6% exhibited high blood pressure ( > = 140/90), and 54.8% did not have a current primary care provider. This project demonstrated that conducting HCV and other health screenings at food distribution sites within Cherokee Nation was an effective strategy to engage AI/AN people in preventive health screenings. Future programs are needed to scale-up preventive health screenings outside of traditional medical facilities as these types of screenings may help to decrease the HCV disparities among AI/AN people.

Unsettling Settler Colonialism in Research: Strategies Centering Native American Experience and Expertise in Responding to Substance Misuse and Co-occurring Sexual Risk-Taking, Alcohol-Exposed Pregnancy, and Suicide Prevention Among Young People

Native American (NA) populations in the USA (i.e., those native to the USA which include Alaska Natives, American Indians, and Native Hawaiians) have confronted unique historical, sociopolitical, and environmental stressors born of settler colonialism. Contexts with persistent social and economic disadvantage are critical determinants of substance misuse and co-occurring sexual risk-taking and suicide outcomes, as well as alcohol exposed pregnancy among NA young people (i.e., adolescents and young adults). Despite intergenerational transmission of resistance and resiliencies, NA young people face continued disparities in substance misuse and co-occurring outcomes when compared to other racial and ethnic groups in the USA. The failure in progress to address these inequities is the result of a complex set of factors; many of which are structural and rooted in settler colonialism. One of these structural factors includes barriers evident in health equity research intended to guide solutions to address these disparities yet involving maintenance of a research status quo that has proven ineffective to developing these solutions. Explicitly or implicitly biased values, perspectives, and practices are deeply rooted in current research design, methodology, analysis, and dissemination and implementation efforts. This status quo has been supported, intentionally and unintentionally, by researchers and research institutions with limited experience or knowledge in the historical, social, and cultural contexts of NA communities. We present a conceptual framework illustrating the impact of settler colonialism on current research methods and opportunities to unsettle its influence. Moreover, our framework illustrates opportunities to resist settler colonialism in research. We then focus on case examples of studies from the Intervention Research to Improve Native American Health program, funded by the NIH, that impact substance use and co-occurring health conditions among NA young people.

Culturally tailored digital therapeutic for substance use disorders with urban Indigenous people in the United States: A randomized controlled study

INTRODUCTION

Indigenous people experience health disparities, including higher rates of substance use disorders (SUDs). Digital therapeutics are a growing platform for treatment services and have the potential to expand access to culturally responsive interventions for Indigenous people. As one of the first randomized controlled trials for SUDs for American Indian and Alaska Native (AI/AN) adults, the aim of this study was to pilot test the efficacy of a culturally tailored intervention among urban Indigenous adults.

METHODS

The study used a randomized controlled parallel design of 12 weeks of treatment-as-usual (TAU) (n = 26) versus TAU + Therapeutic Education System-Native Version (TES-NAV) (n = 27) with follow-up assessments at end of treatment and week 24 in an urban outpatient addiction treatment program for Native American adults. TAU consisted of individual/group counseling and cultural activities. The TES-NAV arm comprised TAU + 26 self-directed culturally tailored digital skills-based modules grounded in the community reinforcement approach with contingency management for abstinence and module completion. Primary outcome was longest consecutive weeks of abstinence from drugs and heavy drinking measured using self-report (Timeline Followback) and urine alcohol and drug toxicology screen during 12 weeks of treatment. Secondary outcomes were percent days abstinence during and posttreatment, coping strategies, social connectedness, and substance use and sexual risk behaviors.

RESULTS

The study enrolled fifty-three (52.8 % male) AI/AN adults seeking treatment for a SUD. Although the study did not detect a benefit of TAU+TES-NAV over TAU on the primary outcome (Median = 2 consecutive weeks of abstinence for both arms) at end of treatment (treatment effect: Z = -0.78, p = 0.437), TAU+TES-NAV participants did demonstrate significantly greater percent days of abstinence at the week 24 follow-up (69.3 % versus 49.0 % for TAU; t = 2.08, p = 0.045) and significantly greater change in social connectedness mean score, baseline to week 12 (Z = -2.66, p = 0.011), compared to TAU. The study detected no differences between treatment arms for coping strategies or risk behaviors.

CONCLUSION

The addition of TES-NAV to TAU did not significantly improve consecutive weeks of abstinence from drugs or heavy drinking; however, several secondary findings suggest promise for a culturally tailored digital therapeutic SUD intervention among urban Indigenous people.

CLINICAL TRIALS

GOV REGISTRATION: #NCT03363256.

The CPT1A Arctic variant: perspectives of community members and providers in two Alaska tribal health settings

Newborn screening in Alaska includes screening for carnitine palmitoyltransferase 1A (CPT1A) deficiency. The CPT1A Arctic variant is a variant highly prevalent among Indigenous peoples in the Arctic. In this study, we sought to elicit Alaska Native (AN) community member and AN-serving healthcare providers' knowledge and perspectives on the CPT1A Arctic variant. Focus groups with community members and healthcare providers were held in two regions of Alaska between October 2018 and January 2019. Thematic analysis was used to identify recurring constructs. Knowledge and understanding about the CPT1A Arctic variant and its health impact varied, and participants were interested in learning more about it. Additional education for healthcare professionals was recommended to improve providers' ability to communicate with family caregivers about the Arctic variant. Engagement with AN community members identified opportunities to improve educational outreach via multiple modalities for providers and caregivers on the Arctic variant, which could help to increase culturally relevant guidance and avoid stigmatization, undue worry, and unnecessary intervention. Education and guidance on the care of infants and children homozygous for the CPT1A Arctic variant could improve care and reduce negative psychosocial effects.

Provider- and System-Level Barriers and Facilitators to Colonoscopy and Multi-Target Stool DNA for Colorectal Cancer Screening in Rural/Remote Alaska Native Communities

The Alaska Tribal Health System is working to increase colorectal cancer (CRC) screening among Alaska Native people, who experience the highest CRC rates in the world. This study examined CRC screening provider- and system-level barriers and facilitators from the perspective of healthcare providers serving Alaska Native people in rural/remote communities. A total of 28 provider (physicians, advanced practice, and Community Health Aides/Practitioners) interviews were held from 1 February to 30 November 2021. Colonoscopy provider-level barrier themes included time, competing priorities, and staffing, while system-level barriers included travel costs, weather, and the COVID-19 pandemic. Multi-target stool DNA (mt-sDNA) barrier themes included test viability and unfamiliarity, and previous stool tests experiences. For both tests, limited medical record reminders was a major barrier. Facilitator themes for both tests included community outreach, cultural competency and patient navigation, and clinic/system improvements. In-depth interviews with tribal health providers showed that adding mt-sDNA testing may help address system-level colonoscopy barriers such as waitlists and travel costs, but other barriers remain. Further research is needed into patient barriers and facilitators, as well as the effectiveness of integrating mt-sDNA into a geographically dispersed tribal health system to reduce cancer disparities and build equity in CRC prevention among Alaska Native people.

Supporting Traditional Foodways Knowledge and Practices in Alaska Native Communities: The Elders Mentoring Elders Camp

The transmission of generational knowledge in Alaska Native communities has been disrupted by colonization and led to declining health among Alaska Natives, as evidenced by the loss of knowledge regarding traditional foods and foodways and increasing rates of cardiometabolic disorders impacting Alaska Natives. Elders play a central role in passing down this generational knowledge, but emerging Elders may have difficulty in stepping into their roles as Elders due to the rapid social and cultural changes impacting their communities. The Center for Alaska Native Health Research (CANHR) and the Denakkanaaga Elders Program are partnering with the Center for Indigenous Innovation and Health Equity to uplift and support traditional food knowledge and practices to promote health in Alaska Native communities. Guided by a decolonizing and Indigenizing framework, researchers at CANHR are working with Athabascan Elders in the Interior of Alaska to strengthen and protect the intergenerational transmission of cultural knowledge and practices for emerging Elders. This community-academic partnership will implement and evaluate an Elders Mentoring Elders Camp to focus on repairing and nurturing relationships through the practice and preservation of cultural knowledge and practices, including traditional foodways. This initiative contributes to the intergenerational transmission of knowledge, which is necessary to keep culture alive and thriving.

The Development of a Community-Led Alaska Native Traditional Foods Gathering

Traditional foods and foodways are a critical part of health and well-being for Alaska Native/American Indian (ANAI) peoples. However, many of these foods are being replaced by ultra-processed foods high in fat, sugar, and sodium. The cultural knowledge needed to gather, hunt, and fish to acquire these foods is not being passed down to younger generations, due to lingering effects of colonialism, leading to poor health outcomes among ANAI peoples. Southcentral Foundation (SCF) and the Center for Indigenous and Health Equity (CIIHE) are using community-based participatory research to identify and prioritize food sovereignty interventions to strengthen the transmission of cultural knowledge across generations and improve ANAI health. Through the implementation of a comprehensive landscape analysis and the development of a community advisory board, SCF has planned an Alaska Native Traditional Foods Gathering to highlight regional efforts to document, revitalize, and share cultural food knowledge and practices to build healthy communities.

Food Sovereignty and Health: A Conceptual Framework to Advance Research and Practice

Settler colonialism disrupted traditional Indigenous foodways and practices and created high rates of diet-related disease among Indigenous peoples. Food sovereignty, the rights of Indigenous peoples to determine their own food systems, is a culturally centered movement rooted in traditional Indigenous knowledge. This approach directly intervenes upon systems-level barriers to health, making it an important strategy for health equity. While food sovereignty initiatives can be found within many Indigenous communities, the conceptual linkages between food sovereignty and health have not been well documented within the public health literature. We present a practice-informed conceptual framework developed as part of the Center for Indigenous Innovation and Health Equity (CIIHE) initiative, a community-academic partnership with the goal of strengthening Indigenous food systems and practices to promote health and well-being. The framework emphasizes connectedness, including the transmission of knowledge across generations and the restoration of relational responsibilities, as central to Indigenous concepts of health and wellness.

Healthcare segregation in orthopedic surgery: A statewide analysis of American Indian and Alaska Native patients

Significant health disparities have been described for American Indian and Alaska Native (AIAN) patients undergoing various surgical procedures, however, research into healthcare segregation within orthopedic surgery has been limited. In this study, our purpose was to assess if AIAN patients were more likely to be treated by lower-volume surgeons and at lower-volume hospitals. AIAN and White patients who underwent one of four common orthopedic procedures (knee or hip arthroplasty, femur or tibia repair) were identified from a Washington state inpatient database. Demographic, socioeconomic, geographic, and procedure data were surveyed, and volumetric thresholds were established for lower versus higher volume surgeons and hospitals. Adjusted odds ratios were calculated for AIAN patients receiving care from a lower volume surgeon or hospital, including covariates for patient demographics, geographic, and socioeconomic status. AIAN patients were more likely to receive care from a lower-volume surgeon for all procedures except tibial repair. Adjusted odds ratios of 1.53 (95% confidence interval [CI]: 1.22, 1.92) and 1.68 (95% CI: 1.26, 2.21) were found for AIAN patients receiving knee or hip arthroplasty from a lower volume surgeon, respectively. There was no strong evidence of AIAN patients being more likely to receive care at a lower-volume hospital. Finally, AIAN patients having knee arthroplasty at a higher volume hospital were more likely to have their surgery performed by a lower volume surgeon. These data suggest that there may be significant healthcare segregation among AIAN patients across common orthopedic surgical procedures.

"In the beginning, I said I wouldn't get it.": Hesitant adoption of the COVID-19 vaccine in remote Alaska between November 2020 and 2021

Achieving sufficient COVID-19 vaccination coverage has been hindered in many areas by vaccine hesitancy. Many studies based on large survey samples have characterized vaccine refusal, but there are fewer in-depth qualitative studies that explore hesitant adoption: the middle-ground between vaccine acceptance and refusal, and how individuals may move across this continuum depending on their lived experience. For this paper, we use the narratives of 25 adults living in off-road, predominately Alaska Native communities to describe the complex decision-making processes undertaken by 'hesitant adopters', defined in our study as those who completed their initial COVID-19 series despite reporting hesitancy. Interviewees' stories help illustrate how hesitant adopters' decision-making processes involved making sense of information through interactions with trusted individuals, lived experiences, observations, emotions, and personal motivations. For the majority of these hesitant adopters' (n = 20, 80%) interpersonal interactions were key in helping to make the decision to get vaccinated. Over half of the interviewees (n = 14, 56%) described how conversations with individuals they trusted, including healthcare providers, family, friends, and interactions through their professional network made them feel safe. One third of the hesitant adopters (n = 7, 28%) attributed their decision to get vaccinated based on the influence of Alaska Native Elders including their knowledge, personal experiences, as well as being motivated by the desire to protect them. Independent research was also important to about a quarter of hesitant adopters (n = 6, 24%), and for these interviewees it was the process of gathering information on their own and learning from others, especially healthcare providers who could answer their questions and alleviate their concerns. This paper illustrates the temporality of vaccine decision-making: vaccine acceptance for those who are hesitant may be an ongoing process that is influenced by personal experience, relationships, and context.

Lessons learned and future directions: A scoping review of American Indian and Alaska Native participants in the National Drug Abuse Treatment Clinical Trials Network

INTRODUCTION

American Indian and Alaska Native (AI/AN) populations are disproportionately affected by substance use disorders (SUDs) and related health disparities in contrast to other ethnoracial groups in the United States. Over the past 20 years, substantial resources have been allocated to the National Institute on Drug Abuse Clinical Trials Network (CTN) to disseminate and implement effective SUD treatments in communities. However, we know little about how these resources have benefitted AI/AN peoples with SUD who arguably experience the greatest burden of SUDs. This review aims to determine lessons learned about AI/AN substance use and treatment outcomes in the CTN and the role of racism and Tribal identity.

METHOD

We conducted a scoping review informed by the Joanna Briggs framework and PRISMA Extension for Scoping Reviews checklist and explanation. The study team conducted the search strategy within the CTN Dissemination Library and nine additional databases for articles published between 2000 and 2021. The review included studies if they reported results for AI/AN participants. Two reviewers determined study eligibility.

RESULTS

A systematic search yielded 13 empirical articles and six conceptual articles. Themes from the 13 empirical articles included: (1) Tribal Identity: Race, Culture, and Discrimination; (2) Treatment Engagement: Access and Retention; (3) Comorbid Conditions; (4) HIV/Risky Sexual Behaviors; and (5) Dissemination. The most salient theme was Tribal Identity: Race, Culture, and Discrimination, which was present in all articles that included a primary AI/AN sample (k = 8). Themes assessed but not identified for AI/AN peoples were Harm Reduction, Measurement Equivalence, Pharmacotherapy, and Substance Use Outcomes. The conceptual contributions used AI/AN CTN studies as exemplars of community-based and Tribal participatory research (CBPR/TPR).

CONCLUSION

CTN studies conducted with AI/AN communities demonstrate culturally congruent methods, including CBPR/TPR strategies; consideration/assessment of cultural identity, racism, and discrimination; and CBPR/TPR informed dissemination plans. Although important efforts are underway to increase AI/AN participation in the CTN, future research would benefit from strategies to increase participation of this population. Such strategies include reporting AI/AN subgroup data; addressing issues of cultural identity and experiences of racism; and adopting an overall effort for research aimed at understanding barriers to treatment access, engagement, utilization, retention, and outcomes for both treatment and research disparities for AI/AN populations.

Obesity Prevalence and Dietary Factors Among Preschool-Aged Head Start Children in Remote Alaska Native Communities: Baseline Data from the "Got Neqpiaq?" Study

Background: American Indian and Alaska Native preschool-aged children experience a high prevalence of obesity, yet are under-represented in obesity prevention research. This study examined obesity prevalence and dietary risk factors among Alaska Native preschool-aged children in southwest Alaska. Methods: The study used baseline data from "Got Neqpiaq?" a culturally centered multilevel intervention focused on Yup'ik Alaska Native children, aged 3-5 years, enrolled in Head Start in 12 communities in southwest Alaska (n = 155). The primary outcomes were BMI percentile, overweight, and obesity. Dietary factors of interest were measured using biomarkers: traditional food intake (nitrogen stable isotope ratio biomarker), ultraprocessed food intake (carbon stable isotope ratio biomarker), and vegetable and fruit intake (skin carotenoid status biomarker measured by the Veggie Meter). Cardiometabolic markers (glycated hemoglobin [HbA1c] and blood cholesterol) were also measured. Results: Among the Yup'ik preschool-aged children in the study, the median BMI percentile was 91, and the prevalence of overweight or obesity was 70%. The traditional food intake biomarker was negatively associated with BMI, whereas the ultraprocessed foods and vegetable and fruit biomarkers were not associated with BMI. HbA1c and blood cholesterol were within healthy levels. Conclusions: The burden of overweight and obesity is high among Yup'ik preschool-aged children. Traditional food intake is inversely associated with BMI, which underscores the need for culturally grounded interventions that emphasize traditional values and knowledge to support the traditional food systems in Alaska Native communities in southwest Alaska. Registered with ClinicalTrials.gov #NCT03601299.

What Kinds of Support are Alaska Native Youth and Young Adults Reporting? An Examination of Types, Quantities, Sources, and Frequencies of Support

American Indian and Alaska Native (AI/AN) youth, particularly males, experience disproportionately high rates of suicide compared to other young people in the United States. Therefore, enacting suicide prevention efforts for AI/AN youth is especially important. Since research shows that strengthening social, cultural, and emotional support can reduce suicide risk, many recent prevention efforts focus on these strategies. Yet, to reinforce and to extend the positive impact of these strategies for suicide risk reduction, we argue it is useful to identify baseline levels and other features of already-existing support. Toward this end, we describe the types (i.e., category), quantities (i.e., distribution and average number), sources (i.e., from whom), and frequencies (i.e., how often) of social support that AN young people report receiving, and we examine if these "support profiles" differ by age and sex. We use survey data from 165 ANs under age 30, collected as part of a participatory intervention study focused on Promoting Community Conversations About Research to End Suicide (PC CARES). We find that: 1) most ANs reported receiving nearly all supports, 2) compared with females, males reported receiving fewer supports on average, 3) family was the most selected support source, followed by close friends and service providers, and 4) family (e.g., parents, siblings, and grandparents) provided support regularly (i.e., monthly or more). Though our findings may suggest fruitful avenues for interventions targeted toward AN males, we discuss these findings in relation to the gendered nature of suicide prevention and assessment.

Elevated Adenomatous Polyp Detection Rate Among Alaska Native and American Indian People in Interior Alaska, 2018-2022

OBJECTIVES

Colorectal cancer (CRC) incidence and mortality are twice as high among Alaska Native people as among non-Hispanic White people in the United States; as such, colonoscopy is a recommended screening test for Alaska Native people. Adenoma detection rate (ADR) is measured in patients at average risk of CRC undergoing initial screening colonoscopy and reflects the prevalence of precancerous polyps in a screened population. We evaluated the ADR among Alaska Native people living in Interior Alaska.

METHODS

This project evaluated the ADR among Alaska Native and American Indian adults aged ≥40 years (N = 460) living in Interior Alaska, using a retrospective medical record review of patients referred for screening colonoscopy from February 1, 2018, through March 31, 2022. The main outcome measure was ADR, stratified by age and sex.

RESULTS

The ADR was 45.0% overall: 43.0% among women and 47.1% among men. Among patients aged ≥50 years, the ADR was 67.1%: 62.7% among women and 70.7% among men. Among patients aged 40-49 years, the ADR was 34.4%: 35.3% among women and 33.3% among men.

CONCLUSIONS

Measured ADR was high among Alaska Native men and women aged ≥50 years in Interior Alaska and in all age groups that were screened. These findings have implications for which CRC screening methods, intervals, and age to begin screening are most appropriate for Alaska Native people, as well as the need for future research on the pathology, etiology, and natural history of CRC in this population.

Elder-led cultural identity program as counterspace at a public university: Narratives on sense of community, empowering settings, and empowerment

Higher education institutions present unique settings in which identities and life paths are distinctively shaped. While at their best universities should serve as empowering settings that support their members to grow and develop, to raise awareness of injustice, and to catalyze change, too often systems of higher education in the United States serve to marginalize Indigenous cultures and promote assimilation to White, Euro-American cultures. Counterspaces offer an important response, spaces developed by and for people experiencing oppression that allow for solidarity-building, social support, healing, resource attainment, skill-building, resistance, counter-storytelling, and ideally, empowerment. The Alaska Native (AN) Cultural Identity Project (CIP) is based at an urban U.S.-based university and was rolled out during the COVID-19 pandemic. Developed from the best available scientific and practice literature, local data from AN students, and traditional wisdom from Elders, CIP incorporated storytelling, experiential learning, connection, exploration, and sharing of identity and cultural strengths with the aim of helping AN students understand who they are and who they are becoming. In all, 44 students, 5 Elders, and 3 additional staff participated in the space. In this paper, we sought to understand how CIP was experienced by these unique members who co-created and engaged in this space through 10 focus groups with 36 of the CIP members. We found that the counterspace promoted a sense of community, served as an empowering setting, and set the stage for empowering actions and ripple effects beyond its impact on individuals.

New Collaborative Research on Suicide Prevention, Practice, and Policy With American Indian and Alaska Native Communities Holds Promise for All Peoples

Youth suicide is increasing in the United States, with deaths among younger people of color driving this upward trend. For more than four decades, American Indian and Alaska Native (AIAN) communities have suffered disproportionate rates of youth suicide and years of productive life lost compared to other U.S. Races. The National Institute of Mental Health (NIMH) recently funded three regional Collaborative Hubs to carry out suicide prevention research, practice, and policy development with AIAN communities in Alaska and rural and urban areas of the Southwestern United States. The Hub partnerships are supporting a diverse array of tribally-driven studies, approaches, and policies with immediate value for increasing empirically driven public health strategies to address youth suicide. We discuss unique features of the cross-Hub work, including: (a) long-standing Community-Based Participatory Research processes that led to the Hubs' innovative designs and novel approaches to suicide prevention and evaluation, (b) comprehensive ecological theoretical approaches that contextualize individual risk and protective factors in multilevel social contexts; (c) unique task-shifting and systems of care approaches to increase reach and impact on youth suicide in low-resource settings; and (d) prioritization of strengths-based approaches. The work of the Collaborative Hubs for AIAN youth suicide prevention is generating specific and substantive implications for practice, policy, and research presented in this article at a time when youth suicide prevention is a dire national priority. Approaches also have relevance for historically marginalized communities worldwide.

Disparities in incidence and trends of colorectal, lung, female breast, and cervical cancers among non-Hispanic American Indian and Alaska Native people, 1999-2018

PURPOSE

This study is the first to comprehensively describe incidence rates and trends of screening-amenable cancers (colorectal, lung, female breast, and cervical) among non-Hispanic AI/AN (NH-AI/AN) people.

METHODS

Using the United States Cancer Statistics AI/AN Incidence Analytic Database, we, calculated incidence rates for colorectal, lung, female breast, and cervical cancers for NH-AI/AN and non-Hispanic White (NHW) people for the years 2014-2018 combined. We calculated age-adjusted incidence rates (per 100,000), total percent change in incidence rates between 1999 and 2018, and trends over this time-period using Joinpoint analysis. Screening prevalence by region was calculated using Behavioral Risk Factor Surveillance System data.

RESULTS

Rates of screening-amenable cancers among NH-AI/AN people varied by geographic region and age at diagnosis. Over half of all lung and colorectal cancers in NH-AI/AN people were diagnosed at later stages. Rates of lung and colorectal cancers decreased significantly between 1999-2018 among NH-AI/AN men, but no significant changes were observed in rates of screening-amenable cancers among NH-AI/AN women.

CONCLUSION

This study highlights disparities in screening-amenable cancers between NH-AI/AN and NHW people. Culturally informed, community-based interventions that increase access to preventive health services could reduce cancer disparities among AI/AN people.

Autoimmune hepatitis and overlap syndrome among Alaska Native people: Prevalence, clinical characteristics, and remission

Background and Aim

High autoimmune hepatitis (AIH) and overlap syndrome (OS) prevalence have been previously documented among Alaska Native people. The purpose of this project is to report changes in AIH/OS prevalence over time, clinical characteristics, and factors associated with biochemical remission.

Methods

We reviewed medical records for Alaska Native/American Indian (AN/AI) patients diagnosed with AIH/OS between 1984 and 2021. Point prevalence was calculated based on AIH/OS patients alive at the end of 2021 and at 5-year intervals from July 1, 2000, to July 1, 2020.

Results

We identified 189 AN/AI persons diagnosed with AIH or OS (157 AIH, 32 OS). Of these 189, 137 were alive at the end of 2021 for a point prevalence of 91.2 per 100 000 (95% confidence interval [CI]: 77.2-107.8)-75.9 (95% CI: 63.2-91.2) for AIH and 15.3 (95% CI: 10.2-23.0) for OS. Prevalence for both AIH and OS has risen steadily since 2000. Eighty-nine consented participants (62.7%) achieved biochemical remission with a median time from diagnosis to start of remission of 1.9 years (IQR 0.5-5.0 years). Consented patients with fatty liver were less likely to achieve remission, but their time to remission was shorter than for patients without fatty liver.

Conclusion

The AN/AI population in Alaska continues to have the highest reported prevalence of AIH/OS in the world, with prevalence rising steadily since 2000. High reported AIH/OS prevalence is likely due in part to strong referral networks for liver disease. Detection and treatment can lead to biochemical remission and improved health outcomes.

Incidence of selected cancers in Non-Hispanic American Indian and Alaska Native adolescent and young adult populations, 1999-2019

PURPOSE

Studies have highlighted geographic variation in cancer incidence rates among American Indian and Alaska Native (AI/AN) populations. This is the first study to comprehensively evaluate incidence rates and trends among non-Hispanic AI/AN (NH-AI/AN) adolescents and young adults (AYAs) ages 15-39 years.

METHODS

Using the United States Cancer Statistics AI/AN Incidence Analytic Database, we identified all malignant cancer cases for NH-AI/AN AYA populations for the years 1999-2019. We calculated age-adjusted incidence rates (per 100,000) for NH-AI/AN populations overall, by region, and by age group. We calculated the total percent change in the incidence of leading AYA cancers between 1999 and 2019, and trends by region and cancer type using Joinpoint analysis.

RESULTS

Testicular (13.6) and breast (19.0) cancers had the highest incidence of all AYA cancers in NH-AI/AN males and females, respectively. Overall AYA cancer rates increased by 1.4% in NH-AI/AN males and 1.8% in NH-AI/AN females annually between 1999 and 2019. Increases were observed by age group and geographic region.

CONCLUSIONS

This study describes regional differences in incidence rates of AYA cancers among NH-AI/AN populations. This data can help inform resource and cancer control priorities and strategies to reduce cancer risk and enhance access to quality diagnostic and treatment services for this population.

Indigenous Elder-centered methodology: research that decolonizes and indigenizes

Indigenous research posits that practice-based evidence is fundamental to culturally grounded, multifaceted methods. The objective is to outline the key tenets and characteristics of Elder-centered research and relevant methodology using an interconnected progression of Alaska Native studies. Semi-structured interviews were conducted with 12 Alaska Native Elders, 21 Alaska Native caregivers, and 12 Alaska Native and non-Native caregivers in two studies exploring cultural understandings of memory and successful aging. The design and implementation of these studies employed Elders at every level, ensuring cultural relevance, outcomes, and dissemination. Results reflect the benefits of engaging Alaska Native Elders in research and reveal methods for best practices: (a) creating advisory councils, (b) identifying stakeholders, (c) weaving together Elder and western knowledge systems, and (d) the reciprocal nature of Elder engagement and well-being. This research centers Indigenous values and research for an Elder-centered methodology that encourages engagement of older adults in applicable, meaningful, restorative, and enculturated ways.

Status of Maternal Cardiovascular Health in American Indian and Alaska Native Individuals: A Scientific Statement From the American Heart Association

Cardiovascular disease is the leading cause of pregnancy-related death in the United States. American Indian and Alaska Native individuals have some of the highest maternal death and morbidity rates. Data on the causes of cardiovascular disease-related death in American Indian and Alaska Native individuals are limited, and there are several challenges and opportunities to improve maternal cardiovascular health in this population. This scientific statement provides an overview of the current status of cardiovascular health among American Indian and Alaska Native birthing individuals and causes of maternal death and morbidity and describes a stepwise multidisciplinary framework for addressing cardiovascular disease and cerebrovascular disease during the preconception, pregnancy, and postpartum time frame. This scientific statement highlights the American Heart Association's factors for cardiovascular health assessment known collectively as Life's Essential 8 as they pertain to American Indian and Alaska Native birthing individuals. It summarizes the impact of substance use, adverse mental health conditions, and lifestyle and cardiovascular disease risk factors, as well as the cascading effects of institutional and structural racism and the historical trauma faced by American Indian and Alaska Native individuals. It recognizes the possible impact of systematic acts of colonization and dominance on their social determinants of health, ultimately translating into worse health care outcomes. It focuses on the underreporting of American Indian and Alaska Native disaggregated data in pregnancy and postpartum outcomes and the importance of engaging key stakeholders, designing culturally appropriate care, building trust among communities and health care professionals, and expanding the American Indian and Alaska Native workforce in biomedical research and health care settings to optimize the cardiovascular health of American Indian and Alaska Native birthing individuals.

Feasibility of a Supportive Text Messaging Intervention in Northwest Alaska

Suicide disproportionately impacts young Alaska Native people in the northwestern region of Alaska. As part of its efforts to address this challenge, Maniilaq Association developed a program to determine the feasibility of sending short text messages of caring and support. Process evaluation measures included the number of enrollees and the number of text messages sent each month. To determine participant satisfaction and seek recommendations for improvements, a short, online survey was disseminated to enrollees via text message in 2021 and 2022. Between January 2020 and September 2021, text messages were sent each month to about 100 participants, each with an accompanying image. Messages included "You are capable of amazing things" and "You are enough". Twenty-five individuals completed the 2021 survey and 11 the 2022 survey; three quarters lived in Northwest Arctic. Respondents said the messages improved their mood and made them feel like they mattered a lot or a great deal. The intervention was well-received by participants, inspiring individuals to reach out to others and reach out for help for themselves. Recommendations for improvements included increasing culturally relevant and meaningful quotes and the frequency and consistency of messages. Due to concerns around confidentiality, it is unclear if the initiative reached those most at-risk for suicide. However, participants sharing the messages among the small population of the region may have facilitated a broader reach than would otherwise be expected.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41347-022-00293-z.

Cancer Education for High School Students in the Northwest Arctic Increases Knowledge and Inspires Intent to Share Information and Reduce Cancer Risk

Culturally appropriate cancer education is an opportunity to reduce health inequities in cancer. This manuscript describes the outcomes of piloting cancer education for youth in the Northwest Arctic region of Alaska. The project began due to community concerns, was focused through sharing circles conducted in the region, and was guided by a community advisory board. The project was based on the principles of Community Based Participatory Action Research (CBPAR), honored Indigenous Ways of Knowing, and was grounded in Empowerment Theory. In response to community requests, eleven cancer education lessons were developed for young people in the Northwest Arctic. Several lessons were piloted in spring 2022. Each participant was invited to complete a pre-lesson and a post-lesson survey. A total of 113 surveys were completed from five different lessons: 66 pre-lesson surveys and 47 post-lesson surveys. Respondents' mean cancer knowledge scores were significantly higher after the Cancer Basics lesson. On 98% of post-lesson surveys, respondents said they planned to share cancer education messages such as staying tobacco-free and increasing physical activity with others, including their family, friends, and community members. On 93% of the post-lesson surveys, respondents indicated they planned to make changes to reduce their own personal cancer risk, including by staying tobacco-free, eating healthier, and increasing physical activity. "Cancer is serious, and something we should start talking about".

Recovery from alcohol among urban Alaska Native and American Indian people

Alaska Native and American Indian (ANAI) people experience dramatic alcohol-related health disparities compared to the general US population. Although the majority of ANAI people reside in urban settings (>70%), data are sparse on alcohol abstinence among urban ANAI people with alcohol use disorder (AUD). We conducted a qualitative study using a phenomenological approach to examine the experiences of 20 urban ANAI adults recovering from AUD. Participants' narratives had their own unique dimensions but shared a clear, interrelated trajectory of pre-alcohol recovery, a turning point, and ongoing alcohol recovery. All participants reported a combination of external and internal motivation to stop using alcohol.

Culturally Adapting Caring Contacts for Suicide Prevention in Four Alaska Native and American Indian Communities

AIM

Despite substantial tribal, state, and federal effort, American Indian and Alaska Native (AI/AN) suicide rates have changed little in the last 30 years, prompting attention to new and innovative approaches to this persistent health disparity. Suicide prevention interventions with demonstrated success in other populations may be useful in AI/AN communities. Caring Contacts is a suicide prevention intervention that has been adapted and shown to reduce suicide ideation, attempts, and deaths in other populations.

CONCLUSION

Overall, AI/AN study participants in four diverse AI/AN communities endorsed the use of Caring Contacts for suicide prevention in their communities. Intervention adaptations for use in these communities centered primarily on message frequency and timing as well as expanding access to Caring Contacts. The results of this study may be applicable to other populations that experience suicide-related health disparities.

METHODS

We used a community-based participatory research approach to gather qualitative data from community members, healthcare providers, and leaders in four AI/AN communities. These data were analyzed thematically and used to adapt Caring Contacts for use in a subsequent clinical trial with AI/AN people at high risk for suicide.

RESULTS

A total of 189 community members and other health system stakeholders in four tribal communities participated in focus groups and interviews. Caring Contacts was perceived in all communities to be acceptable. Feedback for intervention adaptations focused on the themes of trial eligibility criteria; instruments; message frequency, timing, and content; and cultural considerations.

Wisconsin Healthcare Utilization Cost Among American Indians/Alaska Natives with and without Alzheimer's Disease and Related Dementias

Individuals with Alzheimer's disease and related dementias (ADRD) accrue higher healthcare utilization costs than peers without ADRD, but incremental costs of ADRD among American Indians/Alaska Natives (AI/AN) is unknown. State-wide paid electronic health record data were retrospectively analyzed using percentile-based bootstrapped 95% confidence intervals of the weighted mean difference of total 5-year billed costs to compare total accrued for non-Tribal and Indian Health Service utilization costs among Medicaid and state program eligible AI/AN, ≥40 years, based on the presence/absence of ADRD (matching by demographic and medical factors). AI/AN individuals with ADRD accrued double the costs compared to those without ADRD, costing an additional $880.45 million to $1.91 billion/year.

Evolving perceptions of COVID-19 vaccines among remote Alaskan communities

Given the dynamic nature of the ongoing pandemic, public knowledge and perceptions about COVID-19 are evolving. Limited transportation options, inconsistent healthcare resources, and lack of water and sanitation infrastructure in many remote Alaskan communities located off the road system have contributed to the experience of the COVID-19 pandemic in these areas. We used longitudinal surveys to evaluate remote Alaskan residents' early vaccine acceptance, vaccine uptake and motivations, risk perceptions regarding COVID-19 vaccines, and likelihood of getting a booster. Slightly over half of respondents showed early vaccine acceptance (November/December 2020), with the highest rate among those over the age of 65 years. However, by March 2021, 80.7% of participants reported receiving the COVID-19 vaccine or planning to get one. Of the unvaccinated, reasons for not getting a vaccine included concerns about side effects and not trusting the vaccine. By September 2021, 88.5% of people had received two doses of a COVID-19 vaccine and 79.7% said they would get the booster (third dose) when it became available. There were misconceptions about vaccine recommendations for pregnant women and effects on fertility and DNA. Although initial vaccine concerns may have subsided, the booster rollout and forthcoming vaccines for youth under 12 years of age present new hurdles for vaccine communication efforts.

Patient and primary care perspectives on hypertension management: short report of a qualitative study in a tribal health system

The prevalence of self-reported hypertension is higher among Alaska Native and American Indian (ANAI) individuals than in the majority USA population. Although hypertension is the primary modifiable risk factor for cardiovascular disease and stroke, it can be difficult to manage successfully. The objective of this study was to explore patients' and providers' perspectives about hypertension, hypertension management strategies, and patient-provider communication strategies within a tribally-owned and operated health system in Alaska. We conducted four focus groups that included 16 ANAI patients and five primary care providers. Patient participants tended to consider hypertension a transient state, in contrast with providers' understanding of hypertension as a chronic condition. Differences were noted in participants' perceptions regarding providers' counselling and education efforts, with providers feeling that current strategies are effective and patients desiring a more personalised discussion about hypertension. Patients expressed preferences for behaviour change approaches compared with pharmacotherapy; providers often resorted to medication as a first step towards controlling blood pressure. Our findings suggest areas of potentially promising future research with respect to patient-provider communication and treatment of hypertension.

Alaska native successful ageing in Northwest Alaska: how family impacts how one ages in a good way

aged well, yet today they experience high rates of illness and lower access to care because of colonisation. Aand this research explores successful ageing from an AN perspective or what it means to achieve "Eldership" in the rural Northwest Alaska. A community-based participatory research approach was used to engage participants at every stage of the research process. Semi-structured interviews were conducted with 16 AN men and 25 women and the interviews were professionally transcribed. Kleinman's explanatory model served as the foundation of the questionnaire to gain a sense of the beliefs about ageing and guide the thematic analysis to establish an AN understanding of successful ageing. The foundation of the Norton Sound southern sub-region Model of Successful Ageing is the reciprocal relationship between Elders and family which enables Elders to access meaningful activities, including Native ways of life, physical health, spirituality, and emotional well-being. Community-based interventions should foster opportunities for Elders to share their Native way of life alongside family and community members, which will enable them to remain physically active, maintain healthy emotional well-being, continue engaging in spiritual practices, and contribute to the health and well-being of families.

Development of a colorectal cancer screening intervention for Alaska Native people during a pandemic year

Objectives

Alaska Native (AN) people experience twice the rate of colorectal cancer (CRC) as US Whites. There is a need for increased screening and early detection. We describe the development and implementation of a randomized controlled trial of the multi-target stool DNA test (mt-sDNA; Cologuard® Exact Sciences, Madison WI) to increase CRC screening among AN people.

Methods

A total of 32 rural/remote AN communities were randomized to a varied intensity intervention (patient navigation vs mailed health education) compared to 14 communities receiving usual opportunistic care. Outcome measures include screening completion and method used (mt-sDNA vs colonoscopy). Health care provider interviews and AN patient focus groups will be used to assess patient-, provider-, and system-level CRC screening promoters and barriers.

Results

The study began in April 2020 during the COVID-19 pandemic, resulting in a number of challenges and study adaptations. These included difficulty finding laboratory space, lack of timely mail service due to flight reductions across the state, and travel restrictions that led to postponement of in-person focus groups. Videoconferencing platforms for Tribal engagement replaced face-to-face interactions. After an extensive search, a laboratory with space available was identified and the preprocessing laboratory established. Study staff will work closely with patients to monitor mail service to get mt-sDNA kits sent on time. We are also exploring the use of videoconferencing platforms as alternatives to in-person focus groups.

Conclusions

Despite the challenges encountered during the COVID-19 pandemic, we successfully initiated the intervention and established the first mt-sDNA preprocessing laboratory in Alaska.

Social Determinants of Health and Body Mass Index in American Indian/Alaska Native Children

Objective: To examine the associations between social determinants of health (SDOH) and prevalent overweight/obesity status and change in adiposity status among American Indian and Alaska Native (AI/AN) children. Methods: The study sample includes 23,950 AI/AN children 2-11 years of age, who used Indian Health Service (IHS) from 2010 to 2014. Multivariate generalized linear mixed models were used to examine the following: (1) cross-sectional associations between SDOH and prevalent overweight/obesity status and (2) longitudinal associations between SDOH and change in adiposity status over time. Results: Approximately 49% of children had prevalent overweight/obesity status; 18% had overweight status and 31% had obesity status. Prevalent severe obesity status was 20% in 6-11-year olds. In adjusted cross-sectional models, children living in counties with higher levels of poverty had 28% higher odds of prevalent overweight/obesity status. In adjusted longitudinal models, children 2-5 years old living in counties with more children eligible for free or reduced-priced lunch had 15% lower odds for transitioning from normal-weight status to overweight/obesity status. Conclusions: This work contributes to accumulating knowledge that economic instability, especially poverty, appears to play a large role in overweight/obesity status in AI/AN children. Research, clinical practice, and policy decisions should aim to address and eliminate economic instability in childhood.

Factors Influencing Palliative Care Access and Delivery for Great Plains American Indians

CONTEXT

Despite the known importance of culturally tailored palliative care (PC), American Indian people (AIs) in the Great Plains lack access to such services. While clinicians caring for AIs in the Great Plains have long acknowledged major barriers to serious illness care, there is a paucity of literature describing specific factors influencing PC access and delivery for AI patients living on reservation land.

OBJECTIVES

This study aimed to explore factors influencing PC access and delivery on reservation land in the Great Plains to inform the development culturally tailored PC services for AIs.

METHODS

Three authors recorded and transcribed interviews with 21 specialty and 17 primary clinicians. A data analysis team of seven authors analyzed transcripts using conventional content analysis. The analysis team met over Zoom to engage in code negotiation, classify codes, and develop themes.

RESULTS

Qualitative analysis of interview data revealed four themes encompassing factors influencing palliative care delivery and access for Great Plains American Indians: health care system operations (e.g., hospice and home health availability, fragmented services), geography (e.g., weather, travel distances), workforce elements (e.g., care continuity, inadequate staffing, cultural familiarity), and historical trauma and racism.

CONCLUSION

Our findings emphasize the importance of addressing the time and cost of travel for seriously ill patients, increasing home health and hospice availability on reservations, and improving trust in the medical system. Strengthening the AI medical workforce, increasing funding for the Indian Health Service, and transitioning the governance of reservation health care to Tribal entities may improve the trustworthiness of the medical system.

Traditional Heart-Healthy Diet and Medication Adherence in the Norton Sound Region: An 18-Month Telehealth Intervention

INTRODUCTION

Innovations are needed for preventing cardiovascular disease (CVD) and for reaching diverse communities in remote regions. The current study reports on a telemedicine-delivered intervention promoting a traditional heart-healthy diet and medication adherence with Alaska Native men and women residing in the Norton Sound region of Alaska.

METHODS

Participants were 299 men and women with high blood pressure or high cholesterol smoking daily who were randomized to receive telemedicine-delivered counseling and printed materials on diet and medication adherence or on smoking and physical activity. Intervention contacts were at baseline and 3-, 6-, and 12-months follow-up, with a final assessment at 18 months. Nutrition outcomes were the ratio of heart-healthy foods and traditional heart-healthy foods relative to all foods reported on a 34-item food frequency questionnaire. Recent and typical adherence for heart medications were self-reported.

RESULTS

Intervention effects were significant for the heart-healthy foods ratio at 6 months only (p = 0.014) and significant for the traditional heart-healthy foods ratio at 6 months only for those aged 47+ (p = 0.031). For recent and typical medication adherence, there were no significant group differences by time.

DISCUSSION

In a remote region of Alaska, telemedicine proved feasible and acceptable for engaging Alaska Native men and women in counseling on CVD risk behaviors. The findings indicate that more touchpoints may be necessary to impart comprehensive lasting change in heart-healthy eating patterns. Medication adherence group differences were not significant; however, medication adherence was high overall.

Validating a predictive algorithm for suicide risk with Alaska Native populations

INTRODUCTION

The American Indian/Alaska Native (AI/AN) suicide rate in Alaska is twice the state rate and four times the U.S. rate. Healthcare systems need innovative methods of suicide risk detection. The Mental Health Research Network (MHRN) developed suicide risk prediction algorithms in a general U.S.

PATIENT POPULATION

METHODS

We applied MHRN predictors and regression coefficients to electronic health records of AI/AN patients aged ≥13 years with behavioral health diagnoses and primary care visits between October 1, 2016, and March 30, 2018. Logistic regression assessed model accuracy for predicting and stratifying risk for suicide attempt within 90 days after a visit. We compared expected to observed risk and assessed model performance characteristics.

RESULTS

10,864 patients made 47,413 primary care visits. Suicide attempt occurred after 589 (1.2%) visits. Visits in the top 5% of predicted risk accounted for 40% of actual attempts. Among visits in the top 0.5% of predicted risk, 25.1% were followed by suicide attempt. The best fitting model had an AUC of 0.826 (95% CI: 0.809-0.843).

CONCLUSIONS

The MHRN model accurately predicted suicide attempts among AI/AN patients. Future work should develop clinical and operational guidance for effective implementation of the model with this population.

Gestational Diabetes and Breastfeeding Among Women of Different Races/Ethnicities: Evidence from the Pregnancy Risk Assessment Monitoring Surveys

OBJECTIVE

To examine risk factors for gestational diabetes mellitus (GDM) and factors associated with breastfeeding patterns among women with GDM from different racial/ethnic groups.

METHODS

We used data from Phase 8 (2016-2018) of the Pregnancy Risk Assessment Monitoring System. We used logistic regression to estimate factors associated with GDM and with breastfeeding initiation, and conducted survival analysis using Kaplan-Meier curves, and Cox proportional hazards regression to analyze early cessation of breastfeeding.

RESULTS

Among American Indian and Alaska Native (AI/AN) women, higher education reduced odds (aOR = 0.33; 95% CI: 0.19-0.59) and being married increased odds (aOR = 1.35; 95% CI: 1.02-1.79) of GDM. AI/AN women who received WIC benefits had lower odds of initiating breastfeeding (aOR = 0.70; 95% CI: 0.51-0.95). While there was no association between GDM and initiation of breastfeeding, only a third of AI/AN women with GDM were still breastfeeding by 36 weeks postpartum, compared to more than half of non-Hispanic White and Hispanic women.

CONCLUSIONS FOR PRACTICE

Efforts to reduce GDM among those most at risk are needed, especially among racial and ethnic minorities. Increasing support for women with GDM to continue to breastfeed may improve maternal and child health outcomes and reduce health disparities, particularly among AI/AN women.

Patterns of Healthcare Use and Mortality After Alzheimer's Disease or Related Dementia Diagnosis Among Alaska Native Patients: Results of a Cluster Analysis in a Tribal Healthcare Setting

Background

Alaska Native and American Indian (AN/AI) people represent a rapidly aging population with disproportionate burdens of Alzheimer's disease and related dementias (ADRD) risk factors.

Objective

To characterize healthcare service use patterns and mortality in the years following ADRD diagnosis for patients in an Alaska Native Tribal health system.

Methods

The study sample included all AN/AI patients aged 55 or older with an ADRD diagnosis who were seen between 2012-2018 (n = 407). We used cluster analysis to identify distinct patterns of healthcare use for primary care, emergency and urgent care, inpatient hospital stays, and selected specialty care. We compared demographic and clinical factors between clusters and used regression to compare mortality.

Results

We identified five clusters of healthcare service use patterns after ADRD diagnosis: 1) people who use a low amount of all services (n = 107), 2) people who use a high amount of all services (n = 60), 3) people who use a high amount of primary and specialty care (n = 105), 4) people who use a high amount of specialty care (n = 65), and 5) people who use a high amount of emergency and urgent care (n = 70). The cluster with the highest use had the greatest proportion of comorbidities and had a 2.3-fold increased risk of mortality compared to the cluster with the lowest healthcare service use.

Conclusion

Results indicate that those receiving the most services had the greatest healthcare-related needs and increased mortality. Future research could isolate factors that predict service use following ADRD diagnosis and identify other differential health risks.

Barriers and Factors Associated with HPV Vaccination Among American Indians and Alaska Natives: A Systematic Review

American Indian and Alaska Native (AI/AN) persons bear a disproportionate burden of human papillomavirus (HPV)-associated cancers and face unique challenges to HPV vaccination. We undertook a systematic review to synthesize the available evidence on HPV vaccination barriers and factors among AI/AN persons in the United States. We searched fourteen bibliographic databases, four citation indexes, and six gray literature sources from July 2006 to January 2021. We did not restrict our search by study design, setting, or publication type. Two reviewers independently screened the titles and abstracts (stage 1) and full-text (stage 2) of studies for selection. Both reviewers then independently extracted data using a data extraction form and undertook quality appraisal and bias assessment using the modified Mixed Methods Appraisal Tool. We conducted thematic synthesis to generate descriptive themes. We included a total of 15 records after identifying 3017, screening 1415, retrieving 203, and assessing 41 records. A total of 21 unique barriers to HPV vaccination were reported across 15 themes at the individual (n = 12) and clinic or provider (n = 3) levels. At the individual level, the most common barriers to vaccination-safety and lack of knowledge about the HPV vaccine-were each reported in the highest number of studies (n = 9; 60%). The findings from this review signal the need to develop interventions that target AI/AN populations to increase the adoption and coverage of HPV vaccination. Failure to do so may widen disparities.

Metabolic Syndrome Among American Indian and Alaska Native Populations: Implications for Cardiovascular Health

PURPOSE OF REVIEW

The latest national data reports a 55% prevalence of metabolic syndrome in American Indian adults compared to 34.7% of the general US adult population. Metabolic syndrome is a strong predictor for diabetes, which is the leading cause of heart disease in American Indian and Alaska Native populations. Metabolic syndrome and associated risk factors disproportionately impact this population. We describe the presentation, etiology, and roles of structural racism and social determinants of health on metabolic syndrome.

RECENT FINDINGS

Much of what is known about metabolic syndrome in American Indian and Alaska Native populations comes from the Strong Heart Study as there is scant literature. American Indian and Alaska Native adults have an increased propensity towards metabolic syndrome as they are 1.1 times more likely to have high blood pressure, approximately three times more likely to have diabetes, and have higher rates of obesity compared with their non-Hispanic White counterparts. Culturally informed lifestyle and behavior interventions are promising approaches to address structural racism and social determinants of health that highly influence factors contributing to these rates. Among American Indian and Alaska Native populations, there is scarce updated literature evaluating the underlying causes of major risk factors for metabolic syndrome, and progression to cardiometabolic disease. As a result, the actual state of metabolic syndrome in this population is not well understood. Systemic and structural changes must occur to address the root causes of these disparities.