A nationwide population-based study identifying health disparities between American Indians/Alaska Natives and the general populations living in select urban counties

Retrospective Study Demonstrating High Rates of Sustained Virologic Response After Treatment With Direct-Acting Antivirals Among American Indian/Alaskan Natives

Background

Treatment for chronic hepatitis C virus (HCV) has rapidly evolved to simple, well-tolerated, all-oral regimens of direct-acting antivirals (DAAs). There are few data on the epidemiology of HCV in American Indians/Alaska Natives (AI/ANs), a population disproportionately affected by HCV.

Methods

In this retrospective cohort study, all HCV-infected AI/AN patients treated with DAA therapies between January 1, 2014, and February 24, 2016, in specialty clinics or by primary care clinicians participating in Extension for Community Healthcare Outcomes (ECHO) were included. Demographic, clinical, and virologic data on all patients treated for HCV from pretreatment through sustained virologic response at 12 weeks (SVR12) were collected.

Results

Two hundred eighty patients were included; 71.1% of patients (n = 199) were infected with genotype 1 (GT1), 18.2% (n = 51) with GT2, and 10.7% with (n = 30) GT3. At baseline, 26.1% (n = 73) patients had cirrhosis and 22.6% (n = 56) had active substance use disorder; eighty-eight percent (n = 232) of patients achieved SVR12. Among the 165 GT1 patients treated with sofosbuvir (SOF)/ledipasvir for 8, 12, and 24 weeks, SVR12 was achieved by 91.5% (n = 54), 92.2% (n = 71), and 100% (n = 13), respectively. Among GT2 patients, 87.2% (n = 34) and 71.4% (n = 5) treated with 12 and 16 weeks of SOF/ribavirin (RBV) achieved SVR12, respectively. Among GT3 patients, 100% (n = 2) and 83.3% (n = 20) treated with 12 and 24 weeks of SOF/RBV achieved SVR12, respectively. SVR12 rates remained high among patients with active substance use disorder.

Conclusions

DAA therapies are highly efficacious in HCV-infected AI/ANs. SVR12 rates remained high among patients with active substance use disorder. More steps must be taken to increase access to treatment for this underserved, vulnerable population.

A County-Level Health Index to Capture Geographic Variation in Health Conditions in North Dakota, South Dakota, and Minnesota

INTRODUCTION

Individual health is influenced by multiple, potentially correlated factors including healthcare availability, community context, and socioeconomic factors. To measure the health changes at county-levels across North Dakota, South Dakota, and Minnesota, a measure of relative health, health index, was developed incorporating multiple indicators from domains of health conditions, health behaviors, and social determinants.

METHODS

We combined data from all 206 counties in the aforementioned three states for the years 2008-2012 from multiple data sources. We performed factor analysis that accounted for a hierarchical structure of the overall health index comprising of 15 indicators.

RESULTS

A hierarchical structure is identified in which three intermediate factors are connecting the health index with 15 health indicators. The grouping results of the 206 counties based on health index values demonstrate the existence of a gradient in health conditions in the Northern Plains.

CONCLUSIONS

The health status of urban areas was generally better than that of rural areas in the Northern Plains during this study period. The developed index adds stability to the estimates of the population characteristics, especially in rural, sparsely populated counties.

Community Protections in American Indian and Alaska Native Participatory Research-A Scoping Review

Experiences with unethical research practices have caused some American Indian and Alaska Native (AIAN) individuals, organizations, and tribes to mistrust health research. To build trust and repair relationships, current research with AIAN peoples often involves participatory research (PR) approaches. This article assesses community-level protections described in the scientific literature on PR involving AIAN communities. A scoping review search in PubMed and PsychInfo for articles published between January 2000 and June 2017 yielded an AIAN PR article dataset. Of 178 articles, a subset of 23 articles that described aspects of community protections were analyzed for descriptions of community-level protection practices. We identified the presence or absence of a description of four community protection measures in each article: a tribal research department, the development of community-level mechanisms for research regulation if not present, community collaboration throughout the research process, and project employment of a community member. The development of community-level mechanisms for research regulation was described in 39% of the articles. Ninety-one percent of these articles described community collaboration during the research process. Seventeen percent included descriptions of all four community-level protection measures. The extent and consistency to which community-level protections are described is variable; the current literature lacks reporting on community-level protection practices specific to tribal communities.

Predictors of Overweight and Obesity in American Indian Families With Young Children

OBJECTIVE

To describe sociodemographic factors and health behaviors among American Indian (AI) families with young children and determine predictors of adult and child weight status among these factors.

DESIGN

Descriptive, cross-sectional baseline data.

SETTING

One urban area and 4 rural AI reservations nationwide.

PARTICIPANTS

A total of 450 AI families with children aged 2-5 years participating in the Healthy Children, Strong Families 2 intervention.

INTERVENTION

Baseline data from a healthy lifestyles intervention.

MAIN OUTCOME MEASURES

Child body mass index (BMI) z-score and adult BMI, and multiple healthy lifestyle outcomes.

ANALYSIS

Descriptive statistics and stepwise regression.

RESULTS

Adult and child combined overweight and obesity rates were high: 82% and 40%, respectively. Food insecurity was high (61%). Multiple lifestyle behaviors, including fruit and vegetable and sugar-sweetened beverage consumption, adult physical activity, and child screen time, did not meet national recommendations. Adult sleep was adequate but children had low overnight sleep duration of 10 h/d. Significant predictors of child obesity included more adults in the household (P = .003; β = 0.153), an adult AI caregiver (P = .02; β = 0.116), high adult BMI (P = .001; β = 0.176), gestational diabetes, high child birth weight (P < .001; β = 0.247), and the family activity and nutrition score (P = .04; β = 0.130).

CONCLUSIONS AND IMPLICATIONS

We found multiple child-, adult-, and household-level factors influence early childhood obesity in AI children, highlighting the need for interventions to mitigate the modifiable factors identified in this study, including early life influences, home environments, and health behaviors.

Inequalities in Young Adult Health Insurance Coverage Post-federal Health Reform

BACKGROUND

Uninsurance for young adults (YAs) was greatly reduced by the Affordable Care Act (ACA). However, reforms may not be equally beneficial for all YAs and certain policies may exacerbate, rather than resolve, pre-existing disparities.

OBJECTIVE

To investigate inequalities in YAs' insurance coverage pre- (2000-2010) and post-federal health reforms (dependent coverage expansion, 2010-2013, and Medicaid/Marketplace expansions, 2014-2016), among a nationally representative sample.

DESIGN

A difference-in-differences estimator (controlling for sociodemographics) was used to determine the effects of the ACA for young adults (ages 19-25) compared to adolescents (ages 13-18) and older YA (ages 26-30) counterparts; triple-difference estimators quantified differential policy effects by sociodemographics.

PARTICIPANTS

Three hundred eighty-seven thousand six hundred thirty-five participants in the 2000-2016 National Health Interview Survey.

MAIN MEASURES

Respondents reported their health insurance coverage types during the last 12 months, reasons uninsured, and detailed sociodemographics.

KEY RESULTS

An adjusted difference-in-differences estimator quantified a 12.3 percentage point increase (p < 0.0001) in full-year coverage post-ACA for YAs compared to older counterparts, driven by increases in employer-sponsored private insurance while younger and older youth saw larger gains in Medicaid coverage. Triple-difference estimators identified subgroups experiencing less beneficial dependent coverage expansion effects, including females, lower socioeconomic status, non-citizens, non-English speakers, and several racial/ethnic minority groups. Later ACA reforms (Marketplace/Medicaid expansions) mitigated many of these widening disparities.

CONCLUSION

While the ACA significantly impacted YA insurance coverage, these gains were not of equal magnitude for all YAs and disparities remain. As such, more work needs to be done to ensure optimal and equitable access to high-quality, affordable insurance for all YAs.

Indigenous patient experiences of returning to country: a qualitative evaluation on the Country Health SA Dialysis bus

BACKGROUND

Rates of End-Stage Kidney Disease among Aboriginal and Torres Strait Islander (Indigenous) Australians in remote areas are disproportionately high; however, haemodialysis is not currently offered in most remote areas. People must therefore leave their 'Country' (with its traditions and supports) and relocate to metropolitan or regional centres, disrupting their kinship and the cultural ties that are important for their wellbeing. The South Australian Mobile Dialysis Truck is a service which visits remote communities for one to two week periods; allowing patients to have dialysis on 'Country', reuniting them with their friends and family, and providing a chance to take part in cultural activities. The aims of the study were to qualitatively evaluate the South Australian Mobile Dialysis Truck program, its impact on the health and wellbeing of Indigenous dialysis patients, and the facilitators and barriers to using the service.

METHODS

Face to face semi-structured interviews were conducted with 15 Indigenous dialysis patients and 10 nurses who had attended trips across nine dialysis units. Realist evaluation methodology and thematic analysis established patient and nursing experiences with the Mobile Dialysis Truck.

RESULTS

The consequences of leaving Country included grief and loss. Barriers to trip attendance included lower trip frequencies, ineffective trip advertisement, lack of appropriate or unavailable accommodation for staff and patients and poor patient health. Benefits of the service included the ability to fulfil cultural commitments, minimisation of medical retrievals from patients missing dialysis to return to remote areas, improved trust and relationships between patients and staff, and improved patient quality of life. The bus also provided a valuable cultural learning opportunity for staff. Facilitators to successful trips included support staff, clinical back-up and a co-ordinator role.

CONCLUSIONS

The Mobile Dialysis Truck was found to improve the social and emotional wellbeing of Indigenous patients who have had to relocate for dialysis, and build positive relationships and trust between metropolitan nurses and remote patients. The trust fostered improved engagement with associated health services. It also provided valuable cultural learning opportunities for nursing staff. This format of health service may improve cultural competencies with nursing staff who provide regular care for Indigenous patients.

Conceptual interdisciplinary model of exposure to environmental changes to address indigenous health and well-being

OBJECTIVES

Global environmental changes not only impact the physical environment but the health and well-being of people on earth. Emerging research demonstrates how indigenous peoples' physical and behavioural health is disproportionately affected by changes to their ecosystems in combination with pre-existing social and economic inequities. This article introduces a conceptual model to enhance our understanding of environmental change and its impact on indigenous behavioural health and well-being.

STUDY DESIGN

Using an indigenous theoretical lens, this article presents a review of existing theoretical frameworks applied to environmental changes and empirical studies with indigenous populations.

METHODS

The conceptual model joins elements from the indigenist stress-coping model from the field of social work with the exposure pathway model from the field of public health.

RESULTS

The interdisciplinary model joins elements from the indigenist stress-coping model with the exposure pathway model to highlight indigenous-specific sensitivities and cultural buffers that are particular to the impacts of environmental change among indigenous peoples.

CONCLUSIONS

Implications for public health and social work policy, practice and research with indigenous communities are discussed.

The impact of people with disabilities choosing their services on quality of life outcomes

BACKGROUND

In recognition of the importance of services and supports that are defined and chosen by the recipient with disabilities, there has been a shift toward person-centered services. Quality person-centered services not only aim to ensure people have control over their own lives, but also to improve individually defined outcomes.

OBJECTIVE

The aim of this study was to explore the relationships between people with disabilities (PWD) choosing their services and their quality of life (QOL).

METHODS

We had two main research questions: 1) what factors predict PWD choosing their services - who was most/least likely to choose their services?; and, 2) how does choosing their services impact the QOL of PWD? To examine these questions, we analyzed Personal Outcome Measures^® interviews from approximately 1100 PWD.

RESULTS

Our findings have revealed that when PWD are able to choose their services, the impact can be widespread.

CONCLUSIONS

By ensuring PWD are able to choose their services, organizations are not only facilitating self-determination, but, ultimately, improving PWD's QOL.

Critical epidemiology in action: Research for and by indigenous peoples

Global social justice movements, including transnational activism for indigenous rights, are working to promote health equity by transforming public health research and policy. Yet little social scientific research has examined how professional epidemiologists are figuring within such efforts. Discussions are unfolding, however, in critical sectors of epidemiology about how to improve the profession's input into advocacy. Findings from a multi-sited ethnographic study of epidemiological research for and by indigenous peoples in three settings (Aotearoa/New Zealand, the continental U.S., and Hawai'i) demonstrate how researchers/practitioners connect epidemiology and advocacy by: (1) linking the better-known legitimacy of quantitative methods to a lesser-known causal framework that positions colonialism as a sociopolitical determinant of health, (2) producing technical critiques that aim to improve the accuracy and accessibility of indigenous population health statistics, and (3) adopting a pragmatic flexibility in response to the shifting political conditions that shape when, whether and how epidemiological findings support advocacy for indigenous health equity. Attending closely to the credibility tactics at hand in this work, and to the skills and sensibilities of its practitioners, charts new directions for future research about epidemiology's contributions to advocacy for health equity.

Randomized Trial of Motivational Interviewing to Prevent Early Childhood Caries in American Indian Children

Introduction

In a randomized controlled trial, the effectiveness of motivational interviewing (MI) combined with enhanced community services (MI + ECS) was compared with ECS alone for reducing dental caries in American Indian children on the Pine Ridge Reservation. The intervention was developed and delivered with extensive tribal collaboration.

Methods

A total 579 mother-newborn dyads were enrolled and randomized to the MI + ECS and ECS groups. They were followed for 36 mo. Four MI sessions were provided, the first shortly after childbirth and then 6, 12, and 18 mo later. Both groups were exposed to ECS, which included public service announcements through billboards and tribal radio, as well as broad distribution of brochures on behavioral risk factors for early childhood caries (ECC), toothbrushes, and toothpaste. MI impact was measured as decayed, missing, and filled tooth surfaces (dmfs). Secondary outcomes included decayed surfaces, caries prevalence, and maternal oral health knowledge and behaviors. Modified intention-to-treat analyses were conducted. Eighty-eight percent of mothers completed at least 3 of 4 MI sessions offered.

Results

After 3 y, dmfs was not significantly different for the 2 groups (MI + ECS = 10, ECS = 10.38, P = 0.68). In both groups, prevalence of caries experience was 7% to 9% after 1 y, 35% to 36% at 2 y, and 55% to 56% at 3 y. Mean knowledge scores increased by 5.0, 5.3, and 5.9 percentage points at years 1, 2, and 3 in the MI + ECS group and by 1.9, 3.3, and 5.0 percentage points in the ECS group (P = 0.03), respectively. Mean maternal oral health behavior scores were not statistically significantly different between the treatment arms.

Conclusion

In summary, the MI intervention appeared to improve maternal knowledge but had no effect on oral health behaviors or on the progression of ECC (ClinicalTrials.gov NCT01116726).

Knowledge Transfer Statement

The findings of this study suggest that motivational interviewing focusing on parental behaviors may not be as effective as previously hoped for slowing the development of childhood caries in some high-risk groups. Furthermore, social factors may be even more salient determinants of oral health than what we previously supposed, perhaps interfering with the capacity to benefit from behavioral strategies that have been useful elsewhere. The improvement of children's oral health in high-risk populations characterized by poverty and multiple related life stresses may require more holistic approaches that address these formidable barriers.

Role of health determinants in a measles outbreak in Ecuador: a case-control study with aggregated data

BACKGROUND

In 2011-2012, an outbreak of measles occurred in Ecuador. This study sought to ascertain which population characteristics were associated.

METHODS

Case-control study of aggregate data. The unit of analysis was the parish (smallest geographic division). The national communicable disease surveillance database was used to identify 52 case parishes (with at least one confirmed case of measles) and 972 control parishes (no cases of measles). A hierarchical model was used to determine the association of measles with population characteristics and access to health care.

RESULTS

Case parishes were mostly urban and had a higher proportion of children under 1 year of age, heads of household with higher educational attainment, larger indigenous population, lower rates of measles immunization, and lower rates of antenatal care visit attendance. On multivariate analysis, associations were found with educational attainment of head of household ≥8 years (OR: 0.29; 95%CI 0.15-0.57) and ≥1.4% indigenous population (OR: 3.29; 95%CI 1.63-6.68). Antenatal care visit attendance had a protective effect against measles (OR: 0.98; 95%CI 0.97-0.99). Measles vaccination was protective of the outbreak (OR: 0.97; 95%CI 0.95-0.98). The magnitude of these associations was modest, but represents the effect of single protective factors, capable of acting at the population level regardless of socioeconomic, biological, and environmental confounding factors.

CONCLUSION

In Ecuador, the parishes with the highest percentage of indigenous populations and those with the lowest vaccination coverage were the most vulnerable during the measles outbreak.

Substance Use Prevention for Urban American Indian Youth: A Efficacy Trial of the Culturally Adapted Living in 2 Worlds Program

This article describes a small efficacy trial of the Living in 2 Worlds (L2W) substance use prevention curriculum, a culturally adapted version of keepin' it REAL (kiR) redesigned for urban American Indian (AI) middle school students. Focused on strengthening resiliency and AI cultural engagement, L2W teaches drug resistance skills, decision making, and culturally grounded prevention messages. Using cluster random assignment, the research team randomized three urban middle schools with enrichment classes for AI students. AI teachers of these classes delivered the L2W curriculum in two schools; the remaining school implemented kiR, unadapted, and became the comparison group. AI students (N = 107) completed a pretest questionnaire before they received the manualized curriculum lessons, and a posttest (85% completion) 1 month after the final lesson. We assessed the adapted L2W intervention, compared to kiR, with paired t tests, baseline adjusted general linear models, and effect size estimates (Cohen's d). Differences between the L2W and kiR groups reached statistically significant thresholds for four outcomes. Youth receiving L2W, compared to kiR, reported less growth in cigarette use from pretest to posttest, less frequent use of the Leave drug resistance strategy, and less loss of connections to AI spirituality and cultural traditions. For other substance use behaviors and antecedents, the direction of the non-significant effects in small sample tests was toward more positive outcomes in L2W and small to medium effect sizes. Results suggest that evidence-based substance use prevention programs that are culturally adapted for urban AI adolescents, like L2W, can be a foundation for prevention approaches to help delay initiation and slow increases in substance use. In addition to study limitations, we discuss implementation challenges in delivering school-based interventions for urban AI populations.

Disparities in Prostate, Lung, Breast, and Colorectal Cancer Survival and Comorbidity Status among Urban American Indians and Alaskan Natives

Cancer is the second leading cause of death among American Indians and Alaskan Natives (AIAN), although cancer survival information in this population is limited, particularly among urban AIAN. In this retrospective cohort study, we compared all-cause and prostate, breast, lung, and colorectal cancer-specific mortality among AIAN (n = 582) and non-Hispanic white (NHW; n = 82,696) enrollees of Kaiser Permanente Northern California (KPNC) diagnosed with primary invasive breast, prostate, lung, or colorectal cancer from 1997 to 2015. Tumor registry and other electronic health records provided information on sociodemographic, comorbidity, tumor, clinical, and treatment characteristics. Cox regression models were used to estimate adjusted survival curves and hazard ratios (HR) with 95% confidence intervals (CI). AIAN had a significantly higher comorbidity burden compared with NHW (P < 0.05). When adjusting for patient, disease characteristics, and Charlson comorbidity scores, all-cause mortality and cancer-specific mortality were significantly higher for AIAN than NHW patients with breast cancer (HR, 1.47; 95% CI, 1.13-1.92) or with prostate cancer (HR, 1.87; 95% CI, 1.14-3.06) but not for AIAN patients with lung and colorectal cancer. Despite approximately equal access to preventive services and cancer care in this setting, we found higher mortality for AIAN than NHW with some cancers, and a greater proportion of AIAN cancer patients with multiple comorbid conditions. This study provides severely needed information on the cancer experience of the 71% of AIANs who live in urban areas and access cancer care outside of the Indian Health Services, from which the vast majority of AIAN cancer information comes. Cancer Res; 77(23); 6770-6. ©2017 AACR.

Oral health beliefs, knowledge, and behaviors in Northern California American Indian and Alaska Native mothers regarding early childhood caries

OBJECTIVES

To assess the oral health beliefs, knowledge, and behaviors related to early childhood caries (ECC) risk in a convenience sample of American Indian and Alaska Native (AIAN) mothers residing in rural Northern California communities.

METHODS

Fifty-three mothers of young children were recruited from three tribal communities in Northern California with the assistance of the California Rural Indian Health Board, Inc. and its California Tribal Epidemiology Center and Dental Support Center. Trained study staff administered questionnaires to obtain basic socio-demographic information, to survey participants on their oral health beliefs, knowledge, and behaviors as related to ECC risk, and to identify possible barriers to their accessing professional oral health care. Analyses of covariance were used to explore associations between socio-demographic indicators and oral health behaviors, after controlling for knowledge, beliefs and barriers to care.

RESULTS

Overall, 53 percent of participants reported their oral health as "fair" or "poor." Mothers' education (high) and being employed were positively associated with better oral health behavior scores. Additionally, 72 percent of mothers reported having one or more barriers to oral health care including access. There was a significant relation (P = 0.03) between high number of reported barriers to oral health care and low oral health behavior scores.

CONCLUSIONS

Despite generally high-level oral health knowledge, perceptions of self and child oral health remains low in this sample of AIAN mothers. Factors identified as being associated with oral health behaviors in this sample were similar to those found in other health disparities populations.

Disparities in infant hospitalizations in Indigenous and non-Indigenous populations in Quebec, Canada

BACKGROUND

Infant mortality is higher in Indigenous than non-Indigenous populations, but comparable data on infant morbidity are lacking in Canada. We evaluated disparities in infant morbidities experienced by Indigenous populations in Canada.

METHODS

We used linked population-based birth and health administrative data from Quebec, Canada, to compare hospitalization rates, an indicator of severe morbidity, in First Nations, Inuit and non-Indigenous singleton infants (< 1 year) born between 1996 and 2010.

RESULTS

Our cohort included 19 770 First Nations, 3930 Inuit and 225 380 non-Indigenous infants. Compared with non-Indigenous infants, all-cause hospitalization rates were higher in First Nations infants (unadjusted risk ratio [RR] 2.05, 95% confidence interval [CI] 1.99-2.11; fully adjusted RR 1.43, 95% CI 1.37-1.50) and in Inuit infants (unadjusted RR 1.96, 95% CI 1.87-2.05; fully adjusted RR 1.37, 95% CI 1.24-1.52). Higher risks of hospitalization (accounting for multiple comparisons) were observed for First Nations infants in 12 of 16 disease categories and for Inuit infants in 7 of 16 disease categories. Maternal characteristics (age, education, marital status, parity, rural residence and Northern residence) partly explained the risk elevations, but maternal chronic illnesses and gestational complications had negligible influence overall. Acute bronchiolitis (risk difference v. non-Indigenous infants, First Nations 37.0 per 1000, Inuit 39.6 per 1000) and pneumonia (risk difference v. non-Indigenous infants, First Nations 41.2 per 1000, Inuit 61.3 per 1000) were the 2 leading causes of excess hospitalizations in Indigenous infants.

INTERPRETATION

First Nations and Inuit infants had substantially elevated burdens of hospitalizations as a result of diseases of multiple systems. The findings identify substantial unmet needs in disease prevention and medical care for Indigenous infants.

Health & access to care among working-age lower income adults in the Great Recession: Disparities across race and ethnicity and geospatial factors

In the United States (US) and elsewhere, residents of low resource areas face health-related disparities, and may experience different outcomes throughout times of severe economic flux. We aimed to identify individual (e.g. sociodemographic) and environmental (e.g. region, rurality) factors associated with self-reported health and forgone medical care due to the cost of treatment in the US across the Great Recession (2008-2009). We analyzed nationally representative data (2004-2010) using the Behavioral Risk Factor Surveillance System in the US. Individual and geospatial factors (rurality, census region) were used to identify differences in self-reported health and forgone medical care due to the cost. Adjusted-analyses taking into account individual and geospatial factors among those with incomes <$50,000 identified multiple differences across time, sex, education, disability, rurality and Census Region for health. Similar analyses for forgone medical care found that those in the Recovery and the Recession were more likely to report forgone care than before the Recession. Having insurance and/or being employed (versus unemployed) was a protective factor in terms of reporting fair/poor health and having to forgo health care due to cost. Policies affecting improvements in health and access for vulnerable populations (e.g., low-income minority adults) are critical. Monitoring trends related to Social Determinants of Health, including the relationship between health and place (e.g. Census region, rurality), is necessary in efforts targeted towards ameliorating disparities.

Evidence of socio-economic stress and female foeticide in racial disparities in the gender ratio at birth in the United States (1995-2014)

BACKGROUND

Males are born in excess of females, expressed as M/T (male/total births), which is expected to approximate 0.515. Racial M/T disparities have been long known. This study was carried out in order to identify such disparities in different races in the United States.

DESIGN

Monthly male and female live births by race for the entire US were obtained from the website of the Centers for Disease Control and Prevention for 1995-2014 for the four racial groups: American Indian or Alaska Native, Asian or Pacific Islander, Black or African American and White.

RESULTS

This study analysed 80805992 live births (M/T 0.5117). M/T was Asian or Pacific Islander>White>American Indian or Alaska Native>Black or African American. The M/T gradient across races was highly significant (p<0.0001).

CONCLUSIONS

The perinatal mortality rate is an important indicator of quality of health care delivery and is expected to approximate 6/1000 births. M/T declines in association with surrogates of socioeconomic status, presumably due to higher stress levels. The lower baseline M/T of Indian or Alaska Native and Black and African American is equivalent to a constant reduction of 3.5-4/1000 male births when compared to White M/T. Race is the most significant variable associated with wealth inequality in the US and may be partially responsible. Sex-selective abortion and the application of a male offspring preference stopping rule is widespread in Asia its immigrants, and in this study is equivalent a constant loss of 3.5 females foetuses per 1000 live births when compared to Whites.

Racial/Ethnic Disparities in Rates of Traumatic Injury in Arizona, 2011-2012

OBJECTIVE

The purpose of this study was to compare the rates of traumatic injury among five racial/ethnic groups in Arizona and to identify which mechanisms and intents of traumatic injury were predominant in each group.

METHODS

We obtained 2011 and 2012 data on traumatic injury from Arizona's trauma registry and data on mortality from Arizona's death registry. We calculated location- and age-adjusted rates (aRs) of traumatic injury and rates of mortality per 100,000 Arizona residents and rate ratios (RRs) for each racial/ethnic group. We also calculated race/ethnicity specific aRs and RRs by mechanism of injury, intent of injury, and alcohol use.

RESULTS

We analyzed data on 58,034 cases of traumatic injury. After adjusting for age and location, American Indians/Alaska Natives (AI/ANs) had the highest overall rate of traumatic injury (n = 6,287; aR = 729) and Asian Americans/Pacific Islanders had the lowest overall rate of traumatic injury (n = 553; aR = 141). By intent, AI/ANs had the highest rate of homicide/assault-related traumatic injury (n = 2,170; aR = 221) and by mechanism, non-Hispanic black/African American people had the highest rate of firearm-related traumatic injury (n = 265; aR = 40). In 2011-2012, 8,868 deaths in Arizona were related to traumatic injury. AI/ANs had the highest adjusted mortality rate (n = 716; aR = 95).

CONCLUSION

Racial/ethnic disparities in traumatic injuries persisted after adjusting for age and injury location. Understanding how these disparities differ by mechanism, intent, and alcohol use may lead to the development of more effective initiatives to prevent traumatic injury.

The effects of perceived racism on psychological distress mediated by venting and disengagement coping in Native Hawaiians

BACKGROUND

Studies have linked perceived racism to psychological distress via certain coping strategies in several different racial and ethnic groups, but few of these studies included indigenous populations. Elucidating modifiable factors for intervention to reduce the adverse effects of racism on psychological well-being is another avenue to addressing health inequities.

METHODS

We examined the potential mediating effects of 14 distinct coping strategies on the relationship between perceived racism and psychological distress in a community-based sample of 145 Native Hawaiians using structural equation modeling.

RESULTS

Perceived racism had a significant indirect effect on psychological distress, mediated through venting and behavioral disengagement coping strategies, with control for age, gender, educational level, and marital status.

DISCUSSION

The findings suggest that certain coping strategies may exacerbate the deleterious effects of racism on a person's psychological well-being.

CONCLUSION

Our study adds Native Hawaiians to the list of U.S. racial and ethnic minorities whose psychological well-being is adversely affected by racism.

Religious and Spiritual Practices Among Home-less Urban American Indians and Alaska Natives with Severe Alcohol Problems

Engagement in religious and spiritual practices may be protective for homeless individuals with alcohol-related problems. However, little is known in this regard for urban-dwelling American Indians and Alaska Natives (AI/ANs) who have disproportionately high rates of homelessness and co-occurring alcohol use problems. Using secondary data from a nonrandomized controlled study testing a Housing First intervention, AI/AN participants (n = 52) and non-AI/AN participants (n = 82) were compared on demographic variables, alcohol use problems, religious affiliations, and religious/spiritual practices (importance, frequency, and type). AI/ANs who engaged in Native-specific independent spiritual practices had significantly lower alcohol use frequency in comparison to AI/ANs who did not.

A Comparison of Early Adolescent Behavioral Health Risks Among Urban American Indians/Alaska Natives and their Peers

We sought to examine behavioral health indicators for an early adolescent population of American Indians/Alaska Natives (AI/AN) within an urban setting in Washington State. We conducted secondary data analyses from a randomized clinical trial implemented in local middle schools that compared AI/ANs (n = 43), non-Hispanic Whites (n = 620), and other racial/ethnic minority youth (n = 527) across a variety of behavioral health risks. AI/AN youth reported significantly more depressive symptoms than other racial/ethnic minorities as well as non-Hispanic Whites. They also reported more discrimination, more generalized anxiety, and were more likely to have initiated substance use, in comparison to non-Hispanic Whites. Psychosocial screening and early intervention are critically needed for AI/AN youth.

Teen pregnancy in Inuit communities - gaps still needed to be filled

Teen pregnancy is depicted around the world as an important cause of health disparities both for the child and the mother. Accordingly, much effort has been invested in its prevention and led to its decline in the northern hemisphere since the mid-1990s. Despite that, high rates are still observed in the circumpolar regions. As Inuit communities have granted better understanding of teenage pregnancy a priority for the coming years, this article comprehensively reviews this multidimensional issue. By depicting current prevalence, likely determinants and possible impacts documented among Inuit of Canada, Alaska and Greenland, and contrasting them to common knowledge that has emerged from other populations over the years, great gaps surface. In some regions, the number of pregnancies per number of Inuit women aged between 15 and 19 years has increased since the turn of the millennium, while statistics from others are either absent or difficult to compare. Only few likely determinants of teenage pregnancy such as low education and some household factors have actually been recognized among Inuit populations. Documented impacts of early pregnancy on Inuit women and their children are also limited compared to those from other populations. As a way to better address early pregnancy in the circumpolar context, the defence for additional scientific efforts and the provision of culturally adapted sexual health prevention programmes appear critical.

Results of a participatory needs assessment demonstrate an opportunity to involve people who use alcohol in drug user activism and harm reduction

Background

Drug users’ organizations have made progress in recent years in advocating for the health and human rights of people who use illicit drugs but have historically not emphasized the needs of people who drink alcohol.

Methods

This paper reports on a qualitative participatory needs assessment with people who use illicit substances in British Columbia, Canada. We held workshops in 17 communities; these were facilitated by people who use illicit drugs, recorded with ethnographic fieldnotes, and analyzed using critical theory.

Results

Although the workshops were targeted to people who use illicit drugs, people who primarily consume alcohol also attended. An unexpected finding was the potential for drug users’ organizations and other harm reduction programs to involve “illicit drinkers”: people who drink non-beverage alcohol (e.g. mouthwash, rubbing alcohol) and those who drink beverage alcohol in criminalized ways (e.g., homeless drinkers). Potential points of alliance between these groups are common priorities (specifically, improving treatment by health professionals and the police, expanding housing options, and implementing harm reduction services), common values (reducing surveillance and improving accountability of services), and polysubstance use.

Conclusions

Despite these potential points of alliance, there has historically been limited involvement of illicit drinkers in drug users’ activism. Possible barriers to involvement of illicit drinkers in drug users’ organizations include racism (as discourses around alcohol use are highly racialized), horizontal violence, the extreme marginalization of illicit drinkers, and knowledge gaps around harm reduction for alcohol. Understanding the commonalities between people who use drugs and people who use alcohol, as well as the potential barriers to alliance between them, may facilitate the greater involvement of illicit drinkers in drug users’ organizations and harm reduction services.

Obesity, Diabetes, and Birth Outcomes Among American Indians and Alaska Natives

Objectives To examine the relationships between prepregnancy diabetes mellitus (DM), gestational diabetes mellitus (GDM), and prepregnancy body mass index, with several adverse birth outcomes: preterm delivery (PTB), low birthweight (LBW), and macrosomia, comparing American Indians and Alaska Natives (AI/AN) with other race/ethnic groups. Methods The sample includes 5,193,386 singleton US first births from 2009-2013. Logistic regression is used to calculate adjusted odds ratios controlling for calendar year, maternal age, education, marital status, Kotelchuck prenatal care index, and child's sex. Results AI/AN have higher rates of diabetes than all other groups, and higher rates of overweight and obesity than whites or Hispanics. Neither overweight nor obesity predict PTB for AI/AN, in contrast to other groups, while diabetes predicts increased odds of PTB for all groups. Being overweight predicts reduced odds of LBW for all groups, but obesity is not predictive of LBW for AI/AN. Diabetes status also does not predict LBW for AI/AN; for other groups, LBW is more likely for women with DM or GDM. Overweight, obesity, DM, and GDM all predict higher odds of macrosomia for all race/ethnic groups. Conclusions for Practice Controlling diabetes in pregnancy, as well as prepregnancy weight gain, may help decrease preterm birth and macrosomia among AI/AN.

Food Insecurity among American Indians and Alaska Natives: A National Profile using the Current Population Survey-Food Security Supplement

Food insecurity increases the risk for obesity, diabetes, hypertension, and cancer-conditions highly prevalent among American Indians and Alaska Natives (AI/ANs). Using the Current Population Survey Food Security Supplement, we analyzed the food insecurity trends of AI/ANs compared to other racial and ethnic groups in the United States from 2000 to 2010. From 2000 to 2010, 25% of AI/ANs remained consistently food insecure and AI/ANs were twice as likely to be food insecure compared to whites. Urban AI/ANs were more likely to experience food insecurity than rural AI/ANs. Our findings highlight the need for national and tribal policies that expand food assistance programs; promote and support increased access to healthy foods and community food security, in both rural and urban areas; and reduce the burden of diet-related disparities on low-income and racial/ethnic minority populations.

Influence of Socioeconomic Factors, Gender and Indigenous Status on Smoking in Taiwan

The indigenous Austronesian minority of Taiwan is heavily affected by health disparities which may include suffering from a greater burden of the tobacco epidemic. While a lack of representative data has historically precluded an investigation of the differences in smoking between Taiwanese ethnicities, these data have recently become available through an annual population-based telephone survey conducted by the Health Promotion Administration, Ministry of Health and Welfare (previously known as the Bureau of Health Promotion (BHP), Department of Health). We used the BHP monitoring data to observe the prevalence of smoking and environmental tobacco smoke exposure among indigenous and non-indigenous Taiwanese surrounding a tobacco welfare tax increase in 2006, investigate ethnic differences in smoking prevalence and environmental tobacco smoke exposure each year between 2005 and 2008, and perform multiple logistic regression to estimate measures of association between potential risk factors and smoking status. Despite significant ethnic and gender differences in smoking prevalence, smoking status was not found to be significantly associated with ethnicity after controlling for socioeconomic and demographic factors.

Integrating Professional and Indigenous Therapies: An Urban American Indian Narrative Clinical Case Study

We present a narrative case study of an urban American Indian male college student who integrated Indigenous and professional therapies during an acute period of stress, loss, and depression. The first published case of an American Indian in an urban context, this article expands on previous clinical cases by focusing on the perspective of the client relative to his own conceptions of help-seeking behaviors. Based on qualitative analysis of five audio-recorded interviews, this case utilizes an innovative methodology to portray four approaches to healing (medication, counseling, bonding, and spirituality), which contribute to holistic well-being. Implications for counseling psychologists include being aware of how some American Indian clients may (a) view professional treatment dynamics through a Native cultural lens (e.g., seeing ideal communication as a "rhythm"); (b) utilize an expanded range of therapeutic agents;

Macrosomia, Perinatal and Infant Mortality in Cree Communities in Quebec, 1996-2010

BACKGROUND

Cree births in Quebec are characterized by the highest reported prevalence of macrosomia (~35%) in the world. It is unclear whether Cree births are at greater elevated risk of perinatal and infant mortality than other First Nations relative to non-Aboriginal births in Quebec, and if macrosomia may be related.

METHODS

This was a population-based retrospective birth cohort study using the linked birth-infant death database for singleton births to mothers from Cree (n = 5,340), other First Nations (n = 10,810) and non-Aboriginal (n = 229,960) communities in Quebec, 1996-2010. Community type was ascertained by residential postal code and municipality name. The primary outcomes were perinatal and infant mortality.

RESULTS

Macrosomia (birth weight for gestational age >90th percentile) was substantially more frequent in Cree (38.0%) and other First Nations (21.9%) vs non-Aboriginal (9.4%) communities. Comparing Cree and other First Nations vs non-Aboriginal communities, perinatal mortality rates were 1.52 (95% confidence intervals 1.17, 1.98) and 1.34 (1.10, 1.64) times higher, and infant mortality rates 2.27 (1.71, 3.02) and 1.49 (1.16, 1.91) times higher, respectively. The risk elevations in perinatal and infant death in Cree communities attenuated after adjusting for maternal characteristics (age, education, marital status, parity), but became greater after further adjustment for birth weight (small, appropriate, or large for gestational age).

CONCLUSIONS

Cree communities had greater risk elevations in perinatal and infant mortality than other First Nations relative to non-Aboriginal communities in Quebec. High prevalence of macrosomia did not explain the elevated risk of perinatal and infant mortality in Cree communities.

Balancing Two Cultures: American Indian/Alaska Native Medical Students' Perceptions of Academic Medicine Careers

American Indians and Alaska Natives (AI/AN) remain underrepresented in the academic medicine workforce and little is known about cultivating AI/AN medical students' interest in academic medicine careers. Five structured focus groups were conducted including 20 medical students and 18 physicians. The discussion guide explored factors influencing AI/AN trainees' academic medicine career interest and recommended approaches to increase their pursuit of academia. Consensual qualitative research was employed to analyze transcripts. Our research revealed six facilitating factors, nine dissuading factors, and five recommendations towards cultivating AI/AN pursuit of academia. Facilitators included the opportunity to teach, serving as a role model/mentor, enhancing the AI/AN medical education pipeline, opportunities to influence institution, collegiality, and financial stability. Dissuading factors included limited information on academic career paths, politics, lack of credit for teaching and community service, isolation, self-doubt, lower salary, lack of positions in rural areas, lack of focus on clinical care for AI/AN communities, and research obligations. Recommendations included heighten career awareness, recognize the challenges in balancing AI/AN and academic cultures, collaborate with IHS on faculty recruitment strategies, identify concordant role models/mentors, and identify loan forgiveness programs. Similar to other diverse medical students', raising awareness of academic career opportunities especially regarding teaching and community scholarship, access to concordant role models/mentors, and supportive institutional climates can also foster AI/AN medical students' pursuit of academia. Unique strategies for AI/AN trainees include learning how to balance AI/AN and academic cultures, collaborating with IHS on faculty recruitment strategies, and increasing faculty opportunities in rural areas.

The Effects of Prepregnancy Body Mass Index and Gestational Weight Gain on Fetal Macrosomia Among American Indian/Alaska Native Women

OBJECTIVES

The American Indian/Alaska Native (AI/AN) population is a high-risk group across many health indicators, including fetal macrosomia. We aimed to investigate the effects of prepregnancy body mass index (BMI) and gestational weight gain (GWG) on macrosomia and explore possible racial and geographical variations among AI/AN women.

METHODS

This retrospective cohort study was conducted from the Pregnancy Risk Assessment Monitoring System in eight states (2004-2011) among live, singleton, term births to AI/AN women 20 years or older. Prevalence of macrosomia (birth weight ≥ 4000 g) by select characteristics were estimated; differences were assessed with Chi-squares. Multivariable logistic regression was conducted to calculate adjusted odds ratios (aOR) for effects on macrosomia of BMI and GWG (enumerating the pounds women deviated from the Institute of Medicine guidelines for GWG) controlling for other factors in the total sample and stratified by race and state of residence.

RESULTS

The prevalence of macrosomia was 14 %, ranging from 8 to 21 % (Utah-Alaska). Among AI/AN women, 30 % were obese prepregnancy and 50 % had excess GWG. Significant independent effects were found for macrosomia of prepregnancy overweight (aOR 1.27; 95 % Confidence Interval 1.01-1.59), obesity (aOR 1.63; 1.29-2.07), and excess GWG (aOR 1.16; 1.13-1.20 per five pounds gained beyond appropriate). Adjusted estimates varied between race and state.

CONCLUSIONS

Prepregnancy BMI and GWG are independent factors for macrosomia among AI/AN women. Future research should prioritize development, testing, and implementation of weight management programs, which account for variations among AI/AN women, both before and during pregnancy for BMI regulation and GWG control.

Causes and Disparities in Death Rates Among Urban American Indian and Alaska Native Populations, 1999-2009

OBJECTIVES

To characterize the leading causes of death for the urban American Indian/Alaska Native (AI/AN) population and compare with urban White and rural AI/AN populations.

METHODS

We linked Indian Health Service patient registration records with the National Death Index to reduce racial misclassification in death certificate data. We calculated age-adjusted urban AI/AN death rates for the period 1999-2009 and compared those with corresponding urban White and rural AI/AN death rates.

RESULTS

The top-5 leading causes of death among urban AI/AN persons were heart disease, cancer, unintentional injury, diabetes, and chronic liver disease and cirrhosis. Compared with urban White persons, urban AI/AN persons experienced significantly higher death rates for all top-5 leading causes. The largest disparities were for diabetes and chronic liver disease and cirrhosis. In general, urban and rural AI/AN persons had the same leading causes of death, although urban AI/AN persons had lower death rates for most conditions.

CONCLUSIONS

Urban AI/AN persons experience significant disparities in death rates compared with their White counterparts. Public health and clinical interventions should target urban AI/AN persons to address behaviors and conditions contributing to health disparities.

Challenges and barriers to health care and overall health in older residents of Alaska: evidence from a national survey

Background

From 1970 to 2010, the Alaskan population increased from 302,583 to 698,473. During that time, the growth rate of Alaskan seniors (65+) was 4 times higher than their national counterparts. Ageing in Alaska requires confronting unique environmental, sociodemographic and infrastructural challenges, including an extreme climate, geographical isolation and less developed health care infrastructure compared to the continental US.

Objective

The objective of this analysis is to compare the health needs of Alaskan seniors to those in the continental US.

Design

We abstracted 315,161 records of individuals age 65+ from the 2013 and 2014 Behavioral Risk Factor Surveillance System, of which 1,852 were residents of Alaska. To compare residents of Alaska to residents of the 48 contiguous states we used generalized linear models which allowed us to adjust for demographic differences and survey weighting procedures. We examined 3 primary outcomes – general health status, health care coverage status and length of time since last routine check-up.

Results

Alaskan seniors were 59% less likely to have had a routine check-up in the past year and 12% less likely to report excellent health status than comparable seniors in the contiguous US.

Conclusions

Given the growth rate of Alaskan seniors and inherent health care challenges this vulnerable population faces, future research should examine the specific pathways through which these disparities occur and inform policies to ensure that all US seniors, regardless of geographical location, have access to high-quality health services.

Perinatal Disparities Between American Indians and Alaska Natives and Other US Populations: Comparative Changes in Fetal and First Day Mortality, 1995-2008

To compare fetal and first day outcomes of American Indian and Alaskan Natives (AIAN) with non-AIAN populations. Singleton deliveries to AIAN and non-AIAN populations were selected from live birth-infant death cohort and fetal deaths files from 1995-1998 and 2005-2008. We examined changes over time in maternal characteristics of deliveries and disparities and changes in risks of fetal, first day (<24 h), and cause-specific deaths. We calculated descriptive statistics, odds ratios and confidence intervals, and ratio of odds ratios (RORs) to indicate changes in disparities. Along with black mothers, AIANs exhibited the highest proportion of risk factors including the highest proportion of diabetes in both time periods (4.6 and 6.5 %). Over time, late fetal death for AIANs decreased 17 % (aOR = 0.83, 95 % CI 0.72-0.97), but we noted a 47 % increased risk over time for Hispanics (aOR = 1.47, 95 % CI 1.40-1.55). Our data indicated no change over time among AIANs for first day death. For AIANs compared to whites, increased risks and disparities persisted for mortality due to congenital anomalies (ROR = 1.28, 95 % CI 1.03-1.60). For blacks compared to AIANs, the increased risks of fetal death (2005-2008: aOR = 0.60, 95 % CI 0.53-0.68) persisted. For Hispanics, lower risks compared to AIANs persisted, but protective effect declined over time. Disparities between AIAN and other groups persist, but there is variability by race/ethnicity in improvement of perinatal outcomes over time. Variability in access to care and pregnancy management should be considered in relation to health equity for fetal and early infant deaths.

Whakawhanaungatanga: the importance of culturally meaningful connections to improve uptake of pulmonary rehabilitation by Māori with COPD - a qualitative study

Background

Pulmonary rehabilitation is known to improve function and quality of life for people with chronic obstructive pulmonary disease (COPD). However, little research has been conducted on the influence of culture on experiences of pulmonary rehabilitation. This study examined factors influencing uptake of pulmonary rehabilitation by Māori with COPD in New Zealand.

Method

Grounded theory nested within kaupapa Māori methodology. Transcripts were analyzed from interviews and focus groups with 15 Māori and ten New Zealand non-Māori invited to attend pulmonary rehabilitation for COPD. Māori participants had either attended a mainstream hospital-based program, a community-based program designed “by Māori, for Māori”, or had experienced both.

Results

Several factors influencing uptake of pulmonary rehabilitation were common to all participants regardless of ethnicity: 1) participants’ past experiences (eg, of exercise; of health care systems), 2) attitudes and expectations, 3) access issues (eg, time, transport, and conflicting responsibilities), and 4) initial program experiences. These factors were moderated by the involvement of family and peers, interactions with health professionals, the way information on programs was presented, and by new illness events. For Māori, however, several additional factors were also identified relating to cultural experiences of pulmonary rehabilitation. In particular, Māori participants placed high value on whakawhanaungatanga: the making of culturally meaningful connections with others. Culturally appropriate communication and relationship building was deemed so important by some Māori participants that when it was absent, they felt strongly discouraged to attend pulmonary rehabilitation. Only the more holistic services offered a program in which they felt culturally safe and to which they were willing to return for ongoing rehabilitation.

Conclusion

Lack of attention to cultural factors in the delivery of pulmonary rehabilitation may be a barrier to its uptake by indigenous, minority ethnic groups, such as New Zealand Māori. Indigenous-led or culturally responsive health care interventions for COPD may provide a solution to this issue.

Alcohol use among Native Americans compared to whites: Examining the veracity of the 'Native American elevated alcohol consumption' belief

BACKGROUND

This study uses national survey data to examine the veracity of the longstanding belief that, compared to whites, Native Americans (NA) have elevated alcohol consumption.

METHODS

The primary data source was the National Survey on Drug Use and Health (NSDUH) from 2009 to 2013: whites (n=171,858) and NA (n=4,201). Analyses using logistic regression with demographic covariate adjustment were conducted to assess differences in the odds of NA and whites being alcohol abstinent, light/moderate drinkers (no binge/heavy consumption), binge drinkers (5+ drinks on an occasion 1-4 days), or heavy drinkers (5+ drinks on an occasion 5+ days) in the past month. Complementary alcohol abstinence, light/moderate drinking and excessive drinking analyses were conducted using Behavioral Risk Factor Surveillance System (BRFSS) data from 2011 to 2013: whites (n=1,130,658) and NA (n=21,589).

RESULTS

In the NSDUH analyses, the majority of NA, 59.9% (95% CI: 56.7-63.1), abstained, whereas a minority of whites, 43.1% (CI: 42.6-43.6), abstained-adjusted odds ratio (AOR): 0.64 (CI: 0.56-0.73). Approximately 14.5% (CI: 12.0-17.4) of NA were light/moderate-only drinkers, versus 32.7% (CI: 32.2-33.2) of whites (AOR: 1.90; CI: 1.51-2.39). NA and white binge drinking estimates were similar-17.3% (CI: 15.0-19.8) and 16.7% (CI: 16.4-17.0), respectively (AOR: 1.00; CI: 0.83-1.20). The two populations' heavy drinking estimates were also similar-8.3% (CI: 6.7-10.2) and 7.5% (CI: 7.3-7.7), respectively (AOR: 1.06; CI: 0.85-1.32). Results from the BRFSS analyses generally corroborated those from NSDUH.

CONCLUSIONS

In contrast to the 'Native American elevated alcohol consumption' belief, Native Americans compared to whites had lower or comparable rates across the range of alcohol measures examined.

Using Electronic Health Records to Examine Disease Risk in Small Populations: Obesity Among American Indian Children, Wisconsin, 2007-2012

Introduction

Tribe-based or reservation-based data consistently show disproportionately high obesity rates among American Indian children, but little is known about the approximately 75% of American Indian children living off-reservation. We examined obesity among American Indian children seeking care off-reservation by using a database of de-identified electronic health records linked to community-level census variables.

Methods

Data from electronic health records from American Indian children and a reference sample of non-Hispanic white children collected from 2007 through 2012 were abstracted to determine obesity prevalence. Related community-level and individual-level risk factors (eg, economic hardship, demographics) were examined using logistic regression.

Results

The obesity rate for American Indian children (n = 1,482) was double the rate among non-Hispanic white children (n = 81,042) (20.0% vs 10.6%, P < .001). American Indian children were less likely to have had a well-child visit (55.9% vs 67.1%, P < .001) during which body mass index (BMI) was measured, which may partially explain why BMI was more likely to be missing from American Indian records (18.3% vs 14.6%, P < .001). Logistic regression demonstrated significantly increased obesity risk among American Indian children (odds ratio, 1.8; 95% confidence interval, 1.6–2.1) independent of age, sex, economic hardship, insurance status, and geographic designation.

Conclusion

An electronic health record data set demonstrated high obesity rates for nonreservation-based American Indian children, rates that had not been previously assessed. This low-cost method may be used for assessing health risk for other understudied populations and to plan and evaluate targeted interventions.

Ethnic differences in birth gender ratio responses in the United States after the September 11 Attacks and the President Kennedy assassination

INTRODUCTION

Male exceed female live births. The ratio is expressed as M/F (male/total live births). Many factors influence this ratio including stress, which depresses it. The 9/11 attacks lowered M/F in the United States a few months after the event. This study was carried out to identify any racial differences in the observed M/F reduction. This paper also analysed racial M/F responses to the assassination of President John Kennedy.

METHODS

For the JKF assassination, births were available as White and Non-White births. For 9/11, births were available for four racial groups: American Indian/Alaska Native, Asian/Pacific, Black/African and White.

RESULTS

For the JFK assassination (November 1963), total M/F was lowest in 1964 (1958-1970, p≤0.01). M/F dipped in March 1964 in Non-White births only (p<0.0001). For 9/11, M/F dips showed a nonsignificant gradient, being greater in Asian/Pacific births, followed by White and Black/African. Baseline M/F was Asian/Pacific>White>Black/African and American Indian/Alaska Native.

DISCUSSION

President Kennedy actively attempted to usher in civil rights, and his assassination may have stressed Non-Whites far more than Whites. For 9/11, the low Black/African M/F dips may be due to chronic stress associated with being overall disadvantaged and of lower socio-economic status. These factors decrease M/F and potentially dampen M/F dips in response to additional stressors. The observed M/F dips often exceed the perinatal mortality statistic. Public Health should be more cognizant of the effect of stress on population M/F as a sentinel health indicator.

KEY GUIDELINES

1. The male to female ratio at birth is decreased by stressful events. 2. This is due to an excess of male foetal losses in established pregnancies. 3. Such losses in response to acute events are transient. 4. This ratio may be a useful indicator of population stress. 5. Socioeconomically deprived subpopulations, such as Black/African and American Indian/Alaska Native races may have a low ratio due to chronic stress and may thus be less responsive to stress in their ratio responses.6. The habitually high ratio in Asian/Pacific subpopulations may be due to the former practicing gender-selective abortion, favouring male over female offspring. RESEARCH DIRECTIONS: 1. Gender ratios in populations could be routinely monitored in order to assess the impact of stressful events that may reduce the male to female birth ratio.

Chronic conditions, functional difficulties, and disease burden among American Indian/Alaska Native children with special health care needs, 2009-2010

The purpose of this study was to determine the prevalence of chronic conditions and functional difficulties of American Indian/Alaska Native (AIAN) children with special health care needs (CSHCN). We conducted bivariate and multivariable analysis of cross-sectional data on 40,202 children from the 2009-2010 National Survey of Children with Special Health Care Needs aged birth through 17 years, including 1,051 AIAN CSHCN. The prevalence of AIAN CSHCN was 15.7 %, not significantly different from the prevalence of US white CSHCN (16.3 %). As qualifiers for special needs status among AIAN children the use of or need for prescription medication was the most frequent (70 %), compared to the lower rates of need for elevated service use (44 %) and emotional, mental, or behavioral treatment/counseling (36 %). Asthma (45 %), conduct disorder (18 %), developmental delay (27 %), and migraine headaches (16 %) were significantly more common chronic conditions among AIAN CSHCN compared to white CSHCN, as were functional difficulties with respiration (52 %), communication (42 %), anxiety/depression (57 %), and behavior (54 %). AIAN CSHCN were also more likely to have 3 or more chronic conditions (39 vs. 28 %, respectively) and 3 or more functional difficulties (70 vs. 55 %, respectively) than white CSHCN. Results indicated a greater impact on the daily activities of AIAN CSHCN compared to white CSHCN (74 vs. 63 %). Significantly greater disease burden among AIAN CSHCN suggests that care must be taken to ensure an appropriate level of coordinated care in a medical home to ameliorate the severity and complexity of their conditions.

Disparities and Trends in Birth Outcomes, Perinatal and Infant Mortality in Aboriginal vs. Non-Aboriginal Populations: A Population-Based Study in Quebec, Canada 1996-2010

BACKGROUND

Aboriginal populations are at substantially higher risks of adverse birth outcomes, perinatal and infant mortality than their non-Aboriginal counterparts even in developed countries including Australia, U.S. and Canada. There is a lack of data on recent trends in Canada.

METHODS

We conducted a population-based retrospective cohort study (n = 254,410) using the linked vital events registry databases for singleton births in Quebec 1996-2010. Aboriginal (First Nations, Inuit) births were identified by mother tongue, place of residence and Indian Registration System membership. Outcomes included preterm birth, small-for-gestational-age, large-for-gestational-age, low birth weight, high birth weight, stillbirth, neonatal death, postneonatal death, perinatal death and infant death.

RESULTS

Perinatal and infant mortality rates were 1.47 and 1.80 times higher in First Nations (10.1 and 7.3 per 1000, respectively), and 2.37 and 4.46 times higher in Inuit (16.3 and 18.1 per 1000, respectively) relative to non-Aboriginal (6.9 and 4.1 per 1000, respectively) births (all p<0.001). Compared to non-Aboriginal births, preterm birth rates were persistently (1.7-1.8 times) higher in Inuit, large-for-gestational-age birth rates were persistently (2.7-3.0 times) higher in First Nations births over the study period. Between 1996-2000 and 2006-2010, as compared to non-Aboriginal infants, the relative risk disparities increased for infant mortality (from 4.10 to 5.19 times) in Inuit, and for postneonatal mortality in Inuit (from 6.97 to 12.33 times) or First Nations (from 3.76 to 4.25 times) infants. Adjusting for maternal characteristics (age, marital status, parity, education and rural vs. urban residence) attenuated the risk differences, but significantly elevated risks remained in both Inuit and First Nations births for the risks of perinatal mortality (1.70 and 1.28 times, respectively), infant mortality (3.66 and 1.47 times, respectively) and postneonatal mortality (6.01 and 2.28 times, respectively) in Inuit and First Nations infants (all p<0.001).

CONCLUSIONS

Aboriginal vs. non-Aboriginal disparities in adverse birth outcomes, perinatal and infant mortality are persistent or worsening over the recent decade in Quebec, strongly suggesting the needs for interventions to improve perinatal and infant health in Aboriginal populations, and for monitoring the trends in other regions in Canada.

Prostate Cancer Screening Among American Indians and Alaska Natives: The Health and Retirement Survey, 1996-2008

Introduction

Among US men, prostate cancer is the leading malignancy diagnosed and the second leading cause of cancer death. Disparities in cancer screening rates exist between American Indians/Alaska Natives and other racial/ethnic groups. Our study objectives were to examine prostate screening at 5 time points over a 12-year period among American Indian/Alaska Native men aged 50 to 75 years, and to compare their screening rates to African American men and white men in the same age group.

Methods

We analyzed Health and Retirement Study data for 1996, 1998, 2000, 2004, and 2008. Prostate screening was measured by self-report of receipt of a prostate examination within the previous 2 years. Age-adjusted prevalence was estimated for each year. We used regression with generalized estimating equations to compare prostate screening prevalence by year and race.

Results

Our analytic sample included 119 American Indian/Alaska Native men (n = 333 observations), 1,359 African American men (n = 3,704 observations), and 8,226 white men (n = 24,292 observations). From 1996 to 2008, prostate screening rates changed for each group: from 57.0% to 55.7% among American Indians/Alaska Natives, from 62.0% to 71.2% among African Americans, and from 68.6% to 71.3% among whites. Although the disparity between whites and African Americans shrank over time, it was virtually unchanged between whites and American Indians/Alaska Natives.

Conclusion

As of 2008, American Indians/Alaska Natives were less likely than African Americans and whites to report a prostate examination within the previous 2 years. Prevalence trends indicated a modest increase in prostate cancer screening among African Americans and whites, while rates remained substantially lower for American Indians/Alaska Natives.

A cost comparison of travel models and behavioural telemedicine for rural, Native American populations in New Mexico

OBJECTIVE

The purpose of this study was to model the cost of delivering behavioural health services to rural Native American populations using telecommunications and compare these costs with the travel costs associated with providing equivalent care.

METHODS

Behavioural telehealth costs were modelled using equipment, transmission, administrative and IT costs from an established telecommunications centre. Two types of travel models were estimated: a patient travel model and a physician travel model. These costs were modelled using the New Mexico resource geographic information system program (RGIS) and ArcGIS software and unit costs (e.g. fuel prices, vehicle depreciation, lodging, physician wages, and patient wages) that were obtained from the literature and US government agencies.

RESULTS

The average per-patient cost of providing behavioural healthcare via telehealth was US$138.34, and the average per-patient travel cost was US$169.76 for physicians and US$333.52 for patients. Sensitivity analysis found these results to be rather robust to changes in imputed parameters and preliminary evidence of economies of scale was found.

CONCLUSION

Besides the obvious benefits of increased access to healthcare and reduced health disparities, providing behavioural telehealth for rural Native American populations was estimated to be less costly than modelled equivalent care provided by travelling. Additionally, as administrative and coordination costs are a major component of telehealth costs, as programmes grow to serve more patients, the relative costs of these initial infrastructure as well as overall per-patient costs should decrease.

How do providers serving American Indians and Alaska Natives with substance abuse problems define evidence-based treatment?

Rates of substance abuse remain high in American Indian and Alaska Native (AI/AN) populations. While there are many evidence-based treatments (EBTs) for substance use problems, no studies exist describing how directors of treatment programs serving AI/ANs perceive and use EBTs. Twenty-one key informant interviews with program administrators and 10 focus groups with clinicians were conducted at 18 treatment programs for AI/ANs with substance use problems. Demographic data were not collected to protect participant privacy. Transcripts were coded to identify relevant themes. A majority of participants correctly defined an EBT using the key terms "effective" and "research" found in standard definitions of the phrase. More detailed descriptions were uncommon. Prevalent themes related to attitudes about EBTs included concerns about cultural relevance, external mandates to use EBTs, and their reliance on western conceptualization of substance abuse. While most administrators and clinicians who treat AI/AN clients for substance abuse had a basic understanding of what constitutes an EBT, there was little consensus regarding their relevance for use with AI/ANs. Recognizing that broad geographic and tribal diversity among AI/AN populations may impact conclusions drawn about EBTs, several factors may enhance the abilities of program staff to identify EBTs most appropriate for local implementation. These include gaining a more detailed understanding of how an EBT is developed and how to assess its scientific grounding, as well as utilizing definitions of EBTs that include not only research evidence, but also clinical expertise and judgment, and fit with consumer choice, preference, and culture.

Poorer Quality Outcomes of Medicare-Certified Home Health Care in Areas With High Levels of Native American/Alaska Native Residents

OBJECTIVE

Compared with most other groups, many Native Americans or Alaska Natives (NA/AN) individuals are concentrated in rural areas, which typically have lower health service availability. We examined whether quality indicators reported to the Centers for Medicare and Medicaid Services (CMS) by Medicare-certified home health care agencies are equal in areas with high NA/AN concentration.

METHOD

We conducted a cross-sectional analysis. The unit of analysis was the ZIP Code Tabulation Area (N = 32,239). The independent variable was NA/AN concentration at/above 4.2% (95th percentile). Dependent variables included risk-adjusted patient self-care quality measures.

RESULTS

Areas with high levels of NA/AN residents had poorer quality outcomes across both utilization (e.g., hospital admission) and improvement measures (e.g., walking, bathing), for 9 of 12 risk-adjusted patient self-care quality measures.

DISCUSSION

Identifying gaps in quality among multiple measures of home health care for high-risk areas allows practitioners and home health care service providers to target quality improvement interventions.

Inuit Elderly: A Systematic Review of Peer Reviewed Journal Articles

Over the last century, Inuit have experienced rapid social changes that have greatly impacted their way of life, health, and intergenerational traditions. Although there is a growing body of research concerning Inuit youth, relatively little is known about elderly Inuit. In an effort to bridge this knowledge gap, a systematic review of peer-reviewed journal articles was conducted. This review identified a dearth of research on older Inuit, and highlighted limitations in service provision to this primarily rural and isolated population. Implications for policy and practice and recommendations for future research are also discussed.

Community perspectives on drug/alcohol use, concerns, needs, and resources in four Washington State Tribal communities

Community-university teams investigated substance use, abuse, and dependence (SUAD) and related concerns, needs, strengths, and resources in four Washington State Tribal communities. A total of 153 key community members shared their perspectives through 43 semi-structured interviews and 19 semi-structured focus groups. Qualitative data analysis revealed robust themes: prescription medications and alcohol were perceived as most prevalent and concerning; family and peer influences and emotional distress were prominent perceived risk factors; and SUAD intervention resources varied across communities. Findings may guide future research and the development of much needed strength-based, culturally appropriate, and effective SUAD interventions for American Indians, Alaska Natives, and their communities.

Persistent Organochlorine Pesticide Exposure Related to a Formerly Used Defense Site on St. Lawrence Island, Alaska: Data from Sentinel Fish and Human Sera

St. Lawrence Island, Alaska, is the largest island in the Bering Sea, located 60 km from Siberia. The island is home to approximately 1600 St. Lawrence Island Yupik residents who live a subsistence way of life. Two formerly used defense sites (FUDS) exist on the island, one of which, Northeast Cape, has been the subject of a $123 million cleanup effort. Environmental monitoring demonstrates localized soil and watershed contamination with polychlorinated biphenyls (PCB), organochlorine (OC) pesticides, mercury, and arsenic. This study examined whether the Northeast Cape FUDS is a source of exposure to OC pesticides. In total, 71 serum samples were collected during site remediation from volunteers who represented three geographic regions of the island. In addition, ninespine stickleback (Pungitius pungitius) and Alaska blackfish (Dallia pectoralis) were collected from Northeast Cape after remediation to assess continuing presence of OC pesticides. Chlordane compounds, DDT compounds, mirex, and hexachlorobenzene (HCB) were the most prevalent and present at the highest concentrations in both fish tissues and human serum samples. After controlling for age and gender, activities near the Northeast Cape FUDS were associated with an increase in serum HCB as compared to residents of the farthest village from the site. Positive but nonsignificant relationships for sum-chlordane and sum-DDT were also found. Organochlorine concentrations in fish samples did not show clear geographic trends, but appear elevated compared to other sites in Alaska. Taken together, data suggest that contamination of the local environment at the Northeast Cape FUDS may increase exposure to select persistent OC pesticides.

American-Indian diabetes mortality in the Great Plains Region 2002-2010

OBJECTIVE

To compare American-Indian and Caucasian mortality rates from diabetes among tribal Contract Health Service Delivery Areas (CHSDAs) in the Great Plains Region (GPR) and describe the disparities observed.

RESEARCH DESIGN AND METHODS

Mortality data from the National Center for Vital Statistics and Seer*STAT were used to identify diabetes as the underlying cause of death for each decedent in the GPR from 2002 to 2010. Mortality data were abstracted and aggregated for American-Indians and Caucasians for 25 reservation CHSDAs in the GPR. Rate ratios (RR) with 95% CIs were used and SEER*Stat V.8.0.4 software calculated age-adjusted diabetes mortality rates.

RESULTS

Age-adjusted mortality rates for American-Indians were significantly higher than those for Caucasians during the 8-year period. In the GPR, American-Indians were 3.44 times more likely to die from diabetes than Caucasians. South Dakota had the highest RR (5.47 times that of Caucasians), and Iowa had the lowest RR, (1.1). Reservation CHSDA RR ranged from 1.78 to 10.25.

CONCLUSIONS

American-Indians in the GPR have higher diabetes mortality rates than Caucasians in the GPR. Mortality rates among American-Indians persist despite special programs and initiatives aimed at reducing diabetes in these populations. Effective and immediate efforts are needed to address premature diabetes mortality among American-Indians in the GPR.

Promoting ethical research with American Indian and Alaska Native people living in urban areas

Most health research with American Indian and Alaska Native (AI/AN) people has focused on tribal communities on reservation lands. Few studies have been conducted with AI/AN people living in urban settings despite their documented health disparities compared with other urban populations. There are unique considerations for working with this population. Engaging key stakeholders, including urban Indian health organization leaders, tribal leaders, research scientists and administrators, and policymakers, is critical to promoting ethical research and enhancing capacity of urban AI/AN communities. Recommendations for their involvement may facilitate an open dialogue and promote the development of implementation strategies. Future collaborations are also necessary for establishing research policies aimed at improving the health of the urban AI/AN population.