Leading causes of death and all-cause mortality in American Indians and Alaska Natives

Sex Differences in Diabetes Prevalence, Comorbidities, and Health Care Utilization among American Indians Living in the Northern Plains

BACKGROUND

The American Indian (AI) population experiences significant diet-related health disparities including diabetes and cardiovascular disease (CVD). Owing to the relatively small sample size of AIs, the population is rarely included in large national surveys such as the NHANES. This exclusion hinders efforts to characterize potentially important differences between AI men and women, track the costs of these disparities, and effectively treat and prevent these conditions.

OBJECTIVE

We examined the sex differences in diabetes prevalence, comorbidity experience, health care utilization, and treatment costs among AIs within a Northern Plains Indian Health Service (IHS) service unit.

METHODS

We assessed data from a sample of 11,144 persons using an IHS service unit in the Northern Plains region of the United States. Detailed analyses were conducted for adults (n = 7299) on prevalence of diabetes by age and sex. We described sex differences in comorbidities, health care utilization, and treatment costs among the adults with diabetes.

RESULTS

In our sample, adult men and women had a similar prevalence of diabetes (10.0% and 11.0%, respectively). The prevalence of CVD among men and women with diabetes was 45.7% and 34.0%, respectively. Among adults with diabetes, men had a statistically higher prevalence of hypertension and substance use disorders than women. The men were statistically less likely to have a non-substance use mental health disorder. Although men had higher utilization and costs for hospital inpatient services than women, the differences were not statistically significant.

CONCLUSIONS

In this AI population, there were differences in comorbidity profiles between adult men and women with diabetes, which have differential mortality and cost consequences. Appropriate diabetes management addressing gender-specific comorbidities, such as substance use disorders for men and non-substance use mental health disorders for women, may help reduce additional comorbidities or complications to diabetes.

Life Expectancy and Mortality Rates in the United States, 1959-2017

Importance

US life expectancy has not kept pace with that of other wealthy countries and is now decreasing.

Objective

To examine vital statistics and review the history of changes in US life expectancy and increasing mortality rates; and to identify potential contributing factors, drawing insights from current literature and an analysis of state-level trends.

Evidence

Life expectancy data for 1959-2016 and cause-specific mortality rates for 1999-2017 were obtained from the US Mortality Database and CDC WONDER, respectively. The analysis focused on midlife deaths (ages 25-64 years), stratified by sex, race/ethnicity, socioeconomic status, and geography (including the 50 states). Published research from January 1990 through August 2019 that examined relevant mortality trends and potential contributory factors was examined.

Findings

Between 1959 and 2016, US life expectancy increased from 69.9 years to 78.9 years but declined for 3 consecutive years after 2014. The recent decrease in US life expectancy culminated a period of increasing cause-specific mortality among adults aged 25 to 64 years that began in the 1990s, ultimately producing an increase in all-cause mortality that began in 2010. During 2010-2017, midlife all-cause mortality rates increased from 328.5 deaths/100 000 to 348.2 deaths/100 000. By 2014, midlife mortality was increasing across all racial groups, caused by drug overdoses, alcohol abuse, suicides, and a diverse list of organ system diseases. The largest relative increases in midlife mortality rates occurred in New England (New Hampshire, 23.3%; Maine, 20.7%; Vermont, 19.9%) and the Ohio Valley (West Virginia, 23.0%; Ohio, 21.6%; Indiana, 14.8%; Kentucky, 14.7%). The increase in midlife mortality during 2010-2017 was associated with an estimated 33 307 excess US deaths, 32.8% of which occurred in 4 Ohio Valley states.

Conclusions and Relevance

US life expectancy increased for most of the past 60 years, but the rate of increase slowed over time and life expectancy decreased after 2014. A major contributor has been an increase in mortality from specific causes (eg, drug overdoses, suicides, organ system diseases) among young and middle-aged adults of all racial groups, with an onset as early as the 1990s and with the largest relative increases occurring in the Ohio Valley and New England. The implications for public health and the economy are substantial, making it vital to understand the underlying causes.

Social Media Intervention to Promote Smoking Treatment Utilization and Cessation Among Alaska Native People Who Smoke: Protocol for the Connecting Alaska Native People to Quit Smoking (CAN Quit) Pilot Study

BACKGROUND

Despite the high prevalence of tobacco use among Alaska Native (AN) people, tobacco cessation interventions developed specifically for this group are lacking. Social media hold promise as a scalable intervention strategy to promote smoking treatment utilization and cessation, given the barriers to treatment delivery (ie, geographic remoteness, limited funding, climate, and travel costs) in the state of Alaska (AK). Building on a longstanding tobacco control research partnership with the AK Tribal Health System, in this study, we are developing and pilot-testing a culturally relevant, Facebook (FB)-delivered intervention that incorporates a digital storytelling approach adapted from the effective Centers for Disease Control Tips from Former Smokers campaign.

OBJECTIVE

This study aims to promote evidence-based smoking treatment (eg, state quitline and Tribal cessation programs) uptake and cessation among AN people.

METHODS

This study fulfills the objectives for stage 1 of the National Institute on Drug Abuse behavioral integrative treatment development program. In stage 1a, we will use a mixed method approach to develop the FB intervention. Cultural variance and surface/deep structure frameworks will address the influence of culture in designing health messages. These developmental activities will include qualitative and quantitative assessments, followed by beta testing of proposed intervention content. In stage 1b, we will conduct a randomized pilot trial enrolling 60 AN adults who smoke. We will evaluate the feasibility, uptake, consumer response, and potential efficacy of the FB intervention compared with a control condition (quitline/treatment referral only). Primary outcome measures include feasibility and biochemically verified smoking abstinence at 1-, 3-, and 6-month follow-ups. Secondary outcomes will include self-reported smoking cessation treatment utilization and abstinence from tobacco/nicotine products. We will also explore interdependence (relationship orientation and collaborative efforts in lifestyle change) as a culturally relevant mediator of intervention efficacy.

RESULTS

The study enrolled 40 participants for phase 1, with data saturation being achieved at 30 AN people who smoke and 10 stakeholders. For phase 2, we enrolled 40 participants. Qualitative assessment of proposed intervention content was completed with 30 AN smokers and 10 stakeholders. We are currently analyzing data from the quantitative assessment with 40 participants in preparation for the beta testing, followed by the randomized pilot trial.

CONCLUSIONS

The project is innovative for its use of social media communication tools that are culturally relevant in a behavioral intervention designed to reach AN people statewide to promote smoking treatment utilization and cessation. The study will further advance tobacco cessation research in an underserved disparity group. If the pilot intervention is successful, we will have a blueprint to conduct a large randomized controlled efficacy trial. Our approach could be considered for other remote AN communities to enhance the reach of evidence-based tobacco cessation treatments.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/15155.

Prostate cancer characteristics and cancer-specific mortality of Native American patients

BACKGROUND

Historical epidemiological data indicate that Native American patients may have worse prostate cancer (PCa) characteristics than Caucasian patients (CAP). To test for cancer-specific mortality (CSM) differences among Native American vs. CAP, the most contemporary version of the SEER database (Surveillance, Epidemiology, and End Results database [2004-2016]) was used.

METHODS

Descriptives and time trend analyses focused on a combined cohort of 357,289 Caucasian and Native American PCa patients of all stages. After 1:4 propensity-score (PS) matching for stage, grade, and other patient characteristics, cumulative incidence plots, and competing-risks-regression-models (CRR) were used, with further stratification according to non-metastatic (T_anyN₀M₀) vs. metastatic (T_anyN₁ and/or M₁) stages.

RESULTS

Native American patients accounted for 1804 (0.5%) of the study cohort. Native American patients had higher PSA (8 ng/ml vs. 6.3 ng/ml), higher rate of D'Amico high-risk PCa (30.8 vs. 24.8%), higher rate of T3/T4-PCa (5.5 vs. 3.7%), higher rate of N1 stage (4.5 vs. 2.8%), and higher rate of M1 stage (7.5 vs. 3.9%, all p < 0.001) than CAP. In T_anyN₀M₀ patients after PS-matching, 10-year CSM was 5.7 vs. 6.2% in Native American vs. CAP. In T_anyN₁ and/or M₁ patients, 10-year CSM was 64.3 vs. 63.3% in Native American vs. CAP, (both p = 0.8). In CRR, Native American race did not represent an independent predictor of CSM.

CONCLUSIONS

Native American patients have more unfavorable stage and grade at presentation. However, after adjustment for these characteristics, CSM in Native American patients is not higher than in CAP. In consequence, PCa prognosis does not differ between Native American and Caucasian race. Therefore, efforts should be made to diagnose PCa in Native Americans at an earlier and more favorable stage like in CAP.

Trends in Cardiovascular Disease Morbidity and Mortality in American Indians Over 25 Years: The Strong Heart Study

Background American Indians experience high rates of cardiovascular disease. We evaluated whether cardiovascular disease incidence, mortality, and prevalence changed over 25 years among American Indians aged 30 to 85. Methods and Results The SHS (Strong Heart Study) and SHFS (Strong Heart Family Study) are prospective studies of cardiovascular disease in American Indians. Participants enrolled in 1989 to 1990 or 2000 to 2003 with birth years from 1915 to 1984 were followed for cardiovascular disease events through 2013. We used Poisson regression to analyze data for 5627 individuals aged 30 to 85 years during follow-up. Outcomes reflect change in age-specific cardiovascular disease incidence, mortality, and prevalence, stratified by sex. To illustrate generational change, 5-year relative risk compared most recent birth years for ages 45, 55, 65, and 75 to same-aged counterparts born 1 generation (23-25 years) earlier. At all ages, cardiovascular disease incidence was lower for people with more recent birth years. Cardiovascular disease mortality declined consistently among men, while prevalence declined among women. Generational comparisons were similar for women aged 45 to 75 (relative risk, 0.39-0.46), but among men magnitudes strengthened from age 45 to 75 (relative risk, 0.91-0.39). For cardiovascular disease mortality, risk was lower in the most recent versus the earliest birth years for women (relative risk, 0.56-0.83) and men (relative risk, 0.40-0.54), but results for women were inconclusive. Conclusions Cardiovascular disease incidence declined over a generation in an American Indian cohort. Mortality declined more for men, while prevalence declined more for women. These trends might reflect more improvement in case survival among men compared with women.

Discrimination in the United States: Experiences of Native Americans

Objective

To examine reported racial discrimination and harassment against Native Americans, which broadly contribute to poor health outcomes.

Data Source and Study Design

Data come from a nationally representative, probability‐based telephone survey including 342 Native American and 902 white US adults, conducted January‐April 2017.

Methods

We calculated the percent of Native Americans reporting discrimination in several domains, including health care. We used logistic regression to compare the Native American‐white difference in odds of discrimination and conducted exploratory analyses among Native Americans only to examine variation by socioeconomic and geographic/neighborhood characteristics.

Principal Findings

More than one in five Native Americans (23 percent) reported experiencing discrimination in clinical encounters, while 15 percent avoided seeking health care for themselves or family members due to anticipated discrimination. A notable share of Native Americans also reported they or family members have experienced violence (38 percent) or have been threatened or harassed (34 percent). In adjusted models, Native Americans had higher odds than whites of reporting discrimination across several domains, including health care and interactions with the police/courts. In exploratory analyses, the association between geographic/neighborhood characteristics and discrimination among Native Americans was mixed.

Conclusions

Discrimination and harassment are widely reported by Native Americans across multiple domains of their lives, regardless of geographic or neighborhood context. Native Americans report major disparities compared to whites in fair treatment by institutions, particularly with health care and police/courts. Results suggest modern forms of discrimination and harassment against Native Americans are systemic and untreated problems.

Barriers to Healthcare Access Facing American Indian and Alaska Natives in Rural America

We provide a literature review concerning healthcare access for Native Americans in rural areas. We group previous research around three themes; barriers in rural America; barriers within the Indian Health Services system (including provider recruitment and retention); and the scale of services offered. Considering a wide range of access measures, a general failure exists in providing Native Americans with services comparable to those received by other Americans There are repeated findings of disparities in specific resources available, such as staff and infrastructure. Improvement appears possible through increased funding, and by giving greater management control to each tribe.

Tobacco Industry Marketing Exposure and Commercial Tobacco Product Use Disparities among American Indians and Alaska Natives

Background: Non-Hispanic American Indians and Alaska Natives (NH AI/AN) have the highest commercial tobacco use (CTU) among U.S. racial/ethnic groups. Tobacco marketing is a risk factor, however few studies examine it among NH AI/AN. Objective: We identified prevalence of tobacco industry marketing exposure and correlates of CTU among NH AI/AN compared to other racial/ethnic groups. Methods: Data were from wave 1 (2013-2014; N = 32,320) of the Population Assessment of Tobacco and Health Study, analyzing self-reported exposure to tobacco ads from stores, tobacco package displays, direct mail and email marketing. Correlates of CTU were identified and interactions between racial/ethnic groups and tobacco marketing were assessed. Results: NH AI/AN (n = 955) had a higher prevalence of exposure to retail tobacco ads (64.5% vs 59.3%; p < 0.05), mail (20.2% vs.14.3%; p < 0.001) and email (17.0% vs.10.6%; p < 0.001) marketing than NH Whites (n = 19,297). Adjusting for tobacco use and related risk factors, exposure to email marketing remained higher among NH AI/AN than NH Whites. Interactions between racial/ethnic groups and marketing exposures on CTU were nonsignificant. CTU was higher among NH AI/AN than NH Whites and among adults who reported exposure to tobacco ads, mail, and email marketing. Conclusions/importance: There is higher tobacco marketing exposure in stores and via mail for NH AI/AN. Email marketing exposure was higher, even after controlling for tobacco-related risk factors. The tobacco industry may be targeting NH AI/AN through emails, which include coupons and other marketing promotions. Culturally relevant strategies that counter-act tobacco industry direct marketing tactics are needed to reduce disparities in this population.

Healthy Food Labels Tailored to a High-Risk, Minority Population More Effectively Promote Healthy Choices than Generic Labels

The decades-long increase in obesity in the US has led to a number of policies aimed at improving diets, which are thought to play a significant role in obesity. Many of these policies seek to influence individuals' behaviors. Front-of-package labels providing salient, easily interpretable information to consumers have exhibited promise in helping people identify and choose healthier foods. However, behavioral economics may offer an opportunity to enhance label effectiveness. Tailoring labels to high-risk communities, including minority and rural populations, which have higher rates of diet-related diseases than the overall population, may increase the label's effectiveness. We conducted a choice experiment with supermarket shoppers on a rural American Indian reservation to test labels tailored to the local population relative to a generic label, which had previously been identified as highly effective in the general population. Results show that while the generic label continues to be quite effective in encouraging healthier choices, the label that is tailored to the local community is more effective, resulting in a marked increase in the premium shoppers were willing to pay for a healthy item. Tailoring healthy food labeling systems using insights from behavioral economics may increase their effectiveness.

Development of a Biomedical Program of Research in the Blackfeet Community: Challenges and Rewards

American Indian (AI) communities have high levels of stress and trauma and are disproportionately affected by numerous preventable diseases. Here, we describe an academic-community partnership based on a collaboration between Blackfeet Community College students and faculty in Psychology and Immunology at Montana State University (MSU). The collaboration, which has spanned over 5 years, was sparked by community interest in the relationship between stress and disease on the Blackfeet reservation. Specifically, community members wanted to understand how the experience of psychological stress and trauma may affect disease risk in their community and identify factors that promote resilience. In doing so, they hoped to identify pathways through which health could be improved for individual community members. Here, we discuss all stages of the collaborative process, including development of measures and methods and themes of research projects, challenges for community members and non-indigenous collaborators, future directions for research, and the lessons learned. Finally, we note the ways in which this partnership and experience has advanced the science of community engagement in tribal communities, with the hope that our experiences will positively affect future collaborations between indigenous community members and non-indigenous scientists.

A Holistic Approach to Chronic Disease Prevention: Good Health and Wellness in Indian Country

The National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention funds the agency's largest investment in Indian Country, Good Health and Wellness in Indian Country. This 5-year program, launched in 2014, supports American Indian and Alaska Native communities and tribal organizations to address chronic diseases and risk factors simultaneously and in coordination. This article describes the development, funding, and implementation of the program. Dialogue with tribal members and leaders helped shape the program, and unlike previous programs that funded a small number of tribes to work on specific diseases, this program funds multiple tribal entities to reach widely into Indian Country. Implementation included culturally developed and adapted practices and opportunities for peer sharing and problem solving. This program identified approaches useful for the Centers for Disease Control and Prevention, other federal agencies, or other organizations working with American Indians and Alaska Natives.

Evaluation of Barriers to Telehealth Programs and Dermatological Care for American Indian Individuals in Rural Communities

Importance

Understanding geographic and financial barriers to health care is an important step toward creating more accessible health care systems. Yet, the barriers to dermatological care access for American Indian populations in rural areas have not been studied extensively.

Objective

To evaluate the driving distances and insurance coverage for dermatological care and the current availability of teledermatological programs within the Indian Health Service (IHS) or tribal hospitals system.

Design, Setting, and Participants

This mixed-methods study was conducted from May 7, 2018, to September 1, 2018, and did not take place in any IHS or tribal health care facility in the continental United States. The study design involved a geographic analysis and a cross-sectional telephone survey with brick-and-mortar dermatology clinics (n = 27) and teledermatological programs (n = 49). Brick-and-mortar clinics were selected for their proximity to a rural IHS or tribal hospital.

Main Outcomes and Measures

Mean driving distance from rural IHS or tribal hospital to nearest dermatology clinic, number of dermatology clinics within a 35-mile or 90-mile radius of IHS or tribal hospitals, insurance and referral types accepted by dermatology clinics, and number of teledermatological programs collaborating with IHS or tribal hospitals or health centers.

Results

In total, 27 brick-and-mortar dermatology clinics and 49 teledermatological programs were identified and contacted for the survey. The median (interquartile range [IQR]) driving distance between rural IHS or tribal hospitals and the nearest dermatology clinic was 68 (30-104) miles. Of the 27 dermatology clinics in closest proximity to rural IHS or tribal hospitals (median [IQR] driving distance, 82.4 [31-114] miles), 25 (93%) responded to the survey, 6 (22%) did not accept patients with Medicaid, and 6 (22%) did not accept IHS referrals for patients without insurance. Of the 49 teledermatological programs, 45 (92%) responded and 14 (29%) were no longer active. Ten (20%) teledermatology programs were currently partnering (n = 6), previously partnered (n = 2), or were setting up services (n = 2) with an IHS or tribal site. Only 9% (n = 27) of the 303 rural IHS or facility in the continental United States reported receiving teledermatological services.

Conclusions and Relevance

Substantial geographic and insurance coverage barriers to dermatological care exist for American Indian individuals in rural communities; teledermatological innovations could represent an important step toward minimizing the disparities in dermatological care access and outcomes.

The Burden of Unintentional Injury Mortality Among American Indians/Alaska Natives in Michigan, Minnesota, and Wisconsin

OBJECTIVES

To characterize the burden of unintentional injury mortality among American Indians/Alaska Natives (AI/ANs) in Michigan, Minnesota, and Wisconsin and identify segments of the population that may especially benefit from policy and practice actions to reduce unintentional injury mortality risk factors.

DESIGN

Surveillance of mortality data from CDC WONDER and WISQARS online databases.

SETTING

The 3 states in the Indian Health Service (IHS) Bemidji Area: Michigan, Minnesota, and Wisconsin.

PARTICIPANTS

AI/ANs and whites who died from unintentional injuries in 2011-2015 in Michigan, Minnesota, and Wisconsin.

MAIN OUTCOME MEASURE

Unintentional injury mortality rates and AI/AN versus white unintentional injury mortality disparity ratios.

RESULTS

For all types of unintentional injury mortality, from 2011 to 2015, AI/ANs in the Bemidji Area died at an age-adjusted rate that was 77% higher than that for whites, a statistically significant difference. For AI/ANs in the 3-state area, the top cause of unintentional death was poisoning. The poisoning rate was a statistically significant 2.64 times as high for AI/ANs as that for whites, the highest disparity seen by type. When analyzed by age, gender, and rural/urban residence, unintentional injury mortality rates were almost always higher for AI/ANs. AI/ANs also had a much higher burden of years of potential life lost.

CONCLUSIONS

Unintentional injury mortality significantly affects AI/ANs in the 3-state area and to a larger degree than for whites. However, some of the risk factors for unintentional injury are modifiable and, if addressed effectively, can reduce injury deaths. Governments, local leaders, organizations, and individuals can reduce AI/ANs' risk of unintentional injury by providing effective programming; encouraging or modeling behavior change; advocating for, creating, and enforcing laws and policies; and making infrastructure improvements. Increased attention to this topic and equitable efforts to reduce risk factors have great potential to reduce the burden of unintentional injury deaths for AI/ANs and all peoples.

Recruitment and effectiveness by cohort in a case management intervention among American Indians and Alaska Natives with diabetes

In real-world settings, eligible populations and intervention effectiveness for a translational intervention likely vary across time. To determine the optimal strategies for effective large-scale implementation of evidence-based interventions, it is critical to investigate these potential variabilities. The purpose of this study is to evaluate whether patient characteristics and intervention effectiveness differed by year of enrollment in a multiyear evidence-based translational intervention. The Special Diabetes Program for Indians Healthy Heart (SDPI-HH) Demonstration Project is an intensive case management intervention designed to reduce cardiovascular disease risk among American Indians and Alaska Natives with diabetes. SDPI-HH participants recruited from 2006 through 2008 were included. Baseline characteristics were compared by year of enrollment. We also evaluated the differences in improvements in clinical and behavioral risk factors for cardiovascular disease among participants recruited in different years. The baseline characteristics of the three cohorts significantly differed in demographics, diabetes duration, health behaviors, level of motivation, and clinical measures. Improvements in 13 clinical and behavioral outcomes also differed by enrollment year with the 2006 cohort having the greatest number of significant improvements and the highest rates of participation and retention. Further investigation into the ways to modify the intensive case management model to address differences in levels of motivation and participation is warranted to improve the management of chronic disease in Indian health. Given the evolving nature of translational initiatives of this kind, our analysis results highlight the need to understand and adapt during the natural progression of health behavioral interventions.

A Narrative Review of the Literature on Insufficient Sleep, Insomnia, and Health Correlates in American Indian/Alaska Native Populations

Insufficient sleep and insomnia promote chronic disease in the general population and may combine with social and economic factors to increase rates of chronic health conditions among AI/AN people. Given that insufficient sleep and insomnia can be addressed via behavioral interventions, it is critical to understand the prevalence and correlates of these disorders among AI/AN individuals in order to elucidate the mechanisms associated with health disparities and provide guidance for subsequent treatment research and practice. We reviewed the available literature on insufficient sleep and insomnia in the AI/AN population. PubMed, PsycINFO, Google Scholar, and ProQuest were searched between June 12th and October 28th of 2018. Prevalence of insufficient sleep ranged from 15% to 40%; insomnia prevalence ranged from 25% to 33%. Insufficient sleep was associated with unhealthy diet, low physical activity levels, higher BMI, worse self-reported health, increased risk for diabetes mellitus, cardiovascular disease, frequent mental distress, smoking, binge drinking, depression, and chronic pain. Insomnia was associated with depression, childhood abuse, PTSD, anxiety, alcohol use, low social support, and low trait-resilience levels. Research on evidence-based treatment and implementation practices targeting insufficient sleep and insomnia was lacking, and only one study described the development/validation of a measure of insufficient sleep among AI/AN people. There is a need for rigorous sleep research including testing and implementation of evidence-based treatment for insufficient sleep and insomnia in this population in an effort to help eliminate health disparities. We present recommendations for research and clinical practice based on the current review.

American Indian women cancer survivors' coping with depressive symptoms

OBJECTIVE

Depressive symptoms have been identified as a primary predictor of quality of life among cancer patients. Depression and cancer are co-occurring and disproportionately elevated for American Indian and Alaska Native (AI/AN) women. The purpose of this article is to examine American Indian (AI) women cancer survivors' coping mechanisms for depressive symptoms.

RESEARCH APPROACH

The methodology included a qualitative descriptive approach with conventional content analysis to examine the coping strategies of AI women cancer survivors associated with depressive symptoms. The interview guide was semi-structured and developed in collaboration with a community advisory board (CAB). Data-derived qualitative analysis was used to generate codes inductively from the data.

PARTICIPANTS

A sample of 43 AI women cancer survivors (n = 14 cervical cancer, n = 14 breast cancer, and n = 15 other cancers) from the Northern Plains region, in the state of South Dakota were interviewed. Data were collected from June 2014 to February 2015. Methodological approach: Qualitative content analysis was used for data analysis, which allowed themes to emerge inductively from the data. Analysis revealed 430 preliminary codes. After de-briefing, validation, and discussion among coauthors, these were then sorted into 67 codes. Member checks with all available participants were conducted to minimize misinterpretation.

FINDINGS

A total of 26 participants (62%) indicated they had feelings of depression since their cancer diagnosis. Women coped with depressive feelings by (a) participating in faith traditions; (b) seeking creative and positive outlets; (c) martialing family and social support; and (d) keeping busy with other life activities.

INTERPRETATION

AI women experienced depressive symptoms following a cancer diagnosis and used a variety of positive coping mechanisms to create personal meaning. Implications for Psychosocial Providers or Policy: AI women may need unique support following a cancer diagnosis, and interventions should incorporate AI beliefs and traditions, such as storytelling and talking with family and community members.

Identifying risk and protective factors related to depressive symptoms among Northern Plains American Indian women cancer survivors

Cancer is the leading cause of death among American Indian and Alaska Native (AIAN) women, and depressive symptoms have been linked to higher mortality, but research on depressive symptoms among AIAN cancer patients has been scant. The purpose of this exploratory study was, using the Framework of Historical Oppression, Resilience, and Transcendence, to examine risk and protective factors related to depressive symptoms in American Indian (AI) women cancer survivors. We examined the relationships of adverse childhood experiences (ACE), perceived health status, resilience, and social support with depressive symptoms in Northern Plains AI women cancer survivors. We used a cross-sectional design with purposive sampling of 73 female cancer survivors (aged 18 years or older) between June 2014 and February 2015. Hierarchical multiple regression was used to test three sets of variables in relation to depressive symptoms: (1) sociodemographics, (2) risk factors (ACE and perceived health), and (3) protective factors (psychological resilience and social support). Approximately 47 percent of participants had probable depressive symptoms. Depressive symptoms were inversely associated with perceived health, psychological resilience, and social support. These results support bolstering existing social support among AI cancer patients and survivors as well as prevention and intervention efforts that strengthen resilience.

Telomere length and cancer mortality in American Indians: the Strong Heart Study

The objective of this study was to investigate whether leukocyte telomere length (LTL) predicts the risk for cancer mortality among American Indians participating in the Strong Heart Study (1989-1991). Participants (aged 45-74 years) were followed annually until December 2015 to collect information on morbidity/mortality. LTL was measured by qPCR using genomic DNA isolated from peripheral blood. The association between LTL and risk for cancer mortality was examined using a multivariable Cox proportional hazard model, adjusting for age, gender, education, study site, smoking, alcohol use, physical activity, systolic blood pressure, fasting blood glucose, obesity, and low- and high-density lipoprotein. Of 1945 participants (mean age 56.10 ± 8.17 at baseline, 57% women) followed for an average 20.5 years, 220 died of cancer. Results showed that longer LTL at baseline significantly predicts an increased risk of cancer death among females (HR 1.57, 95% CI 1.08-2.30), but not males (HR 0.74, 95% CI 0.49-1.12) (p for interaction 0.009). Specifically, compared with the women with the longest LTL (fourth quartile), those in the third, second, and first quartiles showed 53%, 41%, and 44% reduced risk for cancer death, respectively. The findings highlight the importance of sex-specific analysis in future telomere research.

Tobacco Industry Promotional Strategies Targeting American Indians/Alaska Natives and Exploiting Tribal Sovereignty

BACKGROUND

American Indians/Alaska Natives have the highest commercial tobacco use in the United States, resulting in higher tobacco-caused deaths and diseases than the general population. Some American Indians/Alaska Natives use commercial tobacco for ceremonial as well as recreational uses. Because federally recognized Tribal lands are sovereign, they are not subject to state cigarette taxes and smoke-free laws. This study analyzes tobacco industry promotional efforts specifically targeting American Indians/Alaska Natives and exploiting Tribal lands to understand appropriate policy responses in light of American Indians'/Alaska Natives' unique sovereign status and culture.

METHODS

We analyzed previously secret tobacco industry documents available at the Truth Tobacco Documents Library (https://industrydocuments.library.ucsf.edu/tobacco/).

RESULTS

Tobacco companies used promotional strategies targeting American Indians/Alaska Natives and exploiting Tribal lands that leveraged the federally recognized Tribes' unique sovereign status exempting them from state cigarette taxes and smoke-free laws, and exploited some Tribes' existing traditional uses of ceremonial tobacco and poverty. Tactics included price reductions, coupons, giveaways, gaming promotions, charitable contributions, and sponsorships. In addition, tobacco companies built alliances with Tribal leaders to help improve their corporate image, advance ineffective Youth Smoking Prevention programs, and defeat tobacco control policies.

CONCLUSIONS

The industry's promotional tactics likely contribute to disparities in smoking prevalence and smoking-related diseases among American Indians//Alaska Natives. Proven policy interventions to address these disparities including tobacco price increases, cigarette taxes, comprehensive smoke-free laws, and industry denormalization campaigns to reduce smoking prevalence and smoking-related disease could be considered by Tribal communities. The sovereign status of federally recognized Tribes does not prevent them from adopting these measures.

IMPLICATIONS

American Indians/Alaska Natives suffer disparities in smoking prevalence and smoking-related diseases as compared with other groups. The tobacco industry has used promotional tactics including price reductions, coupons and giveaways, casino and bingo promotions, charitable contributions and sponsorships, and so-called Youth Smoking Prevention (YSP) programs to specifically target American Indians/Alaska Natives and exploit Tribal sovereignty, which likely contribute to disparities in tobacco use and related diseases and deaths among this population. Tribal and public health policy makers should consider rejecting ineffective YSP programs and instead consider adopting proven policy interventions including tobacco price increases, cigarette and casino taxes, comprehensive smokefree laws, and anti-industry denormalization campaigns to reduce smoking and smoking-related disease.

The Resilience of Indigenous Women of the U.S. Who Experience Cancer: Transcending Adversity

Almost no research specifically explores resilience among Indigenous women of the U.S. who experience cancer. A qualitative descriptive study included a sample of 43 Indigenous women from the Northern Plains region of the U.S. Almost 90% (88%, n=37) of participants indicated personal growth in response to having cancer, indicating they valued relationships (n=3), had a stronger faith (n=5), were grateful and living in moment (n=21), were healthier (n=5), and helped others (n=6) in response to their cancer experience. Results indicate that factors that promote and facilitate resilience are critical for culturally responsive practice with Indigenous women.

American Indian Women Cancer Survivor's Needs and Preferences: Community Support for Cancer Experiences

Cancer (the focus of this inquiry) is the leading cause of death among American Indian and Alaska Native women. The purpose of this study was to identify American Indian women cancer survivors' needs and preferences related to community supports for their cancer experience. This qualitative study examined female American Indian cancer survivors' needs and preferences about community support. The sample included 43 American Indian women cancer survivors (the types of cancer survivors included cervical cancer: n = 14; breast cancer: n = 14; and colon and other types: n = 15) residing in the Northern Plains region, in the state of South Dakota. Data were analyzed using qualitative content analysis and were collected between June of 2014 and February of 2015. When asked about their needs and preferences, 82% of participants (n = 35) of female American Indian cancer survivors reported at least one of the following most commonly reported themes: cancer support groups (n = 31, 72%), infrastructure for community support (n = 17, 40%), and cancer education (n = 11, 26%). In addition to the aforementioned themes, 33% of participants (n = 14) indicated the need for an improved healthcare system, with 11% (n = 5) of participants expressly desiring the integration of spirituality and holistic healing options. The majority of American Indian women cancer survivor participants of this study identified a need for more community-based support systems and infrastructures to aid with the cancer survivor experience. Results warrant a community approach to raise awareness, education, and support for American Indian cancer survivors.

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.

How can an Education Workshop Serve as an Intervention for American Indian Screening Participation

American Indians (AIs) continue to have elevated cancer incidence and mortality, and most have issues accessing cancer screening services. During 2013-2014, Mayo and its partners created Native Cancer 101 Module 10 "Prevention and Early Cancer Detection" education workshop. A community-based AI organization implemented nine of these workshops during 2014-2015 via diverse venues. Nearly all participants eligible for at least one type of cancer screening participated in a workshop and consented to follow-up within 3 to 6 months to determine if screenings had been completed or scheduled. Native Cancer 101 Module 10 workshops were conducted with 150 community members of whom 6 had recently completed cancer screening (n = 144). The workshops had a 25.20% increase in knowledge, and 97.1% of subjects responded that they would recommend the workshop to their friends and family. Most (136 of 144) submitted a consent form to be contacted 3 to 6 months following the workshop. Patient navigators reached 86 (63.2%) of the consented participants in the follow-up calls after the workshop, and 63 (46.3%) self-reported that they had completed at least one cancer screening test for which they were eligible. The single implementation of the workshop influenced community participants' completion of cancer screening.

Differences in Injury Characteristics and Outcomes for American Indian/Alaska Native People Hospitalized with Traumatic Injuries: an Analysis of the National Trauma Data Bank

OBJECTIVE

This study compares characteristics of American Indian/Alaska Natives (AI/AN) and non-Hispanic Whites (NHW) hospitalized for traumatic injury and examines the effect of race on hospital disposition.

METHODS

Using 2007-2014 National Trauma Data Bank data, we described differences in demographic and injury characteristics between AI/AN (n = 39,656) and NHWs (n = 3,309,484) hospitalized with traumatic injuries. Multivariable regressions, adjusted for demographic and injury characteristics, compared in-hospital mortality and the risk of discharge to different dispositions (inpatient rehabilitation/long-term care facility, skilled nursing facility, home with home health services) rather than home between AI/AN and NHW patients.

RESULTS

Compared to NHWs, a higher proportion of AI/ANs were age 19-44 (49% versus 27%) years and hospitalized with assault-related injuries (25% versus 5%). AI/ANs had lower odds of dying than NHWs during hospitalization (adjusted odds ratio (aOR) 0.72, 95% CI 0.63-0.84). However, AI/ANs also had lower odds than NHWs to discharge to locations with additional health services even after controlling for injury severity (inpatient rehabilitation/long-term care facilities aOR 0.79, 95% CI 0.67-0.93; skilled nursing facility aOR 0.70, 95% CI 0.49-0.98; home with home health services aOR 0.62, 95% CI 0.49-0.79).

CONCLUSIONS

Injury patterns and acute hospitalization outcomes were significantly different for AI/ANs compared to NHWs. Injury prevention strategies targeting AI/ANs should reflect these differential injury patterns. Outcomes such as disability and access to rehabilitation services should be included when considering the burden of injury among AI/AN communities.

Diabetes-attributable mortality in the United States from 2003 to 2016 using a multiple-cause-of-death approach

AIMS

Deaths attributable to diabetes may be underestimated using an underlying cause of death (COD) approach in U.S. death records. This study sought to characterize the burden of diabetes deaths using a multiple-cause of death approach (underlying and contributing COD) and to identify temporal changes in co-reported causes of death among those with diabetes listed anywhere on their death records.

METHODS

COD were identified using data from the National Center for Health Statistics from 2003 to 2016. We calculated age-adjusted mortality rates for diabetes as the underlying or contributing COD by race/ethnicity. We used ICD-10 codes to identify leading causes of death among those with and without diabetes on their death records. We compared temporal changes in deaths due to cardiovascular disease, cerebrovascular disease, cancer, and other causes.

RESULTS

The study population included 34,313,964 decedents aged ≥25 from 2003 to 2016. Diabetes was listed as an underlying COD in approximately 3.0% (n = 1,031,000) and 6.7% (n = 2,295,510) of the death records, respectively. Decedents with diabetes listed as an underlying COD experienced a 16% decline in mortality, and the race/ethnicity-specific average annual percentage changes (AAPC) showed significant declining trends for most groups (AAPC ranged from 0.18 to -2.83%). Cardiovascular disease remained the leading underlying COD among diabetes-attributable deaths, although its proportion of deaths fell from 31 to 27% over time. Co-reported COD diversified, and were more likely to include hypertension and hypertensive renal disease among those with diabetes on their death records.

CONCLUSIONS

Our findings underscore the importance of using a multiple-cause-of-death approach for more completely characterizing diabetes' contribution to mortality.

Leading Causes of Fatal and Nonfatal Unintentional Injury for Children and Teens and the Role of Lifestyle Clinicians: A Commentary

Unintentional injury and death as a public health concern has not been established in the pediatric population. This is a commentary on a review of epidemiological data of unintentional deaths and injuries with a focus on age, sex, and racial differences in this population. The review takes in-depth look at children aged 0-19 years in the US, followed by a discussion of strategies suggested to address mechanisms of these injuries/deaths. Lifestyle clinicians have a significant role in educating this population and their parent/guardians. Therefore providing insight into the interpretation of the data can support practical education and prevention interventions.

Using Tribal Data Linkages to Improve the Quality of American Indian Cancer Data in Michigan

This study examines the extent to which data linkages between Indian Health Service, tribal data, and cancer registries affect cancer incidence rates among American Indians/Alaska Natives (AI/ANs) in Michigan. The incidence of tobacco- and alcohol-associated cancers for 1995-2012 was analyzed to compare rates of the Upper Peninsula (UP) and Lower Peninsula (LP) in Michigan and among AI/ANs and non-Hispanic Whites (NHWs). Complete linkage resulted in 1,352 additional AI/AN cases; 141 cases were linked via IHS records alone, while 373 were linked via tribal records alone; 838 were linked through both IHS and tribal records. Age-adjusted incidence rates for AI/ANs increased from 214.39 per 100,000 to 405.41 per 100,000, similar to that of NHWs after complete linkage (421.46 per 100,000). In the UP, AI/ANs had age-adjusted incidence rates 1.67 times higher than NHWs (596.69 per 100,000 vs. 356.32 per 100,000 respectively). This study indicates a substantial number of AI/AN cancer cases remain misclassified in Michigan.

Hurricanes and Indigenous Families: Understanding connections with discrimination, social support, and violence on PTSD

The purpose of this article is to use the culturally grounded Framework of Historical Oppression, Resilience, and Transcendence (FHORT) to examine (a) the experiences and impacts of hurricanes on Indigenous (i.e., Native American) family members in the Gulf Coast and (b) to identify how experiencing hurricanes and natural disasters, family and community support, adverse childhood experiences (ACE), discrimination and intimate partner violence (IPV) may be related to post-traumatic stress disorder (PTSD) among two Southeastern tribes. Results were drawn from a convergent mixed-methodology design, which incorporates ethnographic qualitative data and a culturally grounded quantitative follow-up survey. Thematic analysis of qualitative data with 208 participants from a coastal Indigenous community revealed several emergent themes, namely (a) the Impact of Federal Recognition on Hurricane Affected Communities; (b) Rapidly Changing Landscape, Lives, and Communities; and (C) Family and Personal Effects of Hurricane Experiences. Descriptive and hierarchical regression analysis of 127 participants across two Southeastern tribes indicate that many participants frequently thought of losses from hurricanes and disasters and that over one-third of the sample met the criteria for clinically significant PTSD. Regression results affirmed the independent effects of hurricane experiences, ACE, community and family support as they relate to PTSD; yet IPV and discrimination were the strongest predictors of PTSD. Results reveal the extensive repercussions of hurricanes on Indigenous families of the Southeast, which are inseparable from and exacerbated by the insidious historical oppression, including discrimination, already experienced by these groups.

Infant and Youth Mortality Trends by Race/Ethnicity and Cause of Death in the United States

IMPORTANCE

The United States has higher infant and youth mortality rates than other high-income countries, with striking disparities by racial/ethnic group. Understanding changing trends by age and race/ethnicity for leading causes of death is imperative for focused intervention.

OBJECTIVE

To estimate trends in US infant and youth mortality rates from 1999 to 2015 by age group and race/ethnicity, identify leading causes of death, and compare mortality rates with Canada and England/Wales.

DESIGN, SETTING, AND PARTICIPANTS

This descriptive study analyzed death certificate data from the US National Center for Health Statistics, Statistics Canada, and the UK Office of National Statistics for all deaths among individuals younger than 25 years. The study took place from January 1, 1999, to December 31, 2015, and analyses started in September 2017.

EXPOSURES

Race/ethnicity.

MAIN OUTCOMES AND MEASURES

Average annual percent changes in mortality rates from 1999 to 2015 and absolute rate change between 1999 to 2002 and 2012 to 2015 for each age group, race/ethnicity, and cause of death.

RESULTS

Among individuals from birth to age 24 years, 1 169 537 deaths occurred in the United States, 80 540 in Canada, and 121 183 in England/Wales from 1999 to 2015. In the United States, 64% of deaths occurred in male individuals and 52.6% occurred in white individuals (25.1% deaths occurred in black individuals and 17.9% in Latino individuals). All-cause mortality declined for all age groups (infants younger than 1 year [38.5% of deaths], children aged 1-9 years [10.6%], early adolescents aged 10-14 years [5%], late adolescents aged 15-19 years [17.7%], and young adults aged 20-24 years [28.1%]) in the United States, Canada, and England/Wales from 1999 to 2015. However, rates were highest in the United States. Within the United States, annual declines in all-cause mortality rates occurred among all age groups of black, Latino, and white individuals, except for white individuals aged 20 to 24 years, whose rates remained stable. Mortality rates declined across most major causes of death from 1999 to 2002 and 2012 to 2015, with notable declines observed for sudden infant death syndrome, unintentional injury death, and homicides. Among infants, unintentional suffocation and strangulation in bed increased (difference between 2012-2015 and 1999-2002 range, 6.11-29.03 per 100 000). Further, suicide rates among Latino and white individuals aged 10 to 24 years (range, 0.21-2.63 per 100 000) and black individuals aged 10 to 19 years (range, 0.10-0.45 per 100 000) increased, as did unintentional injury deaths in white young adults (0.79 per 100 000). The rise in unintentional injury deaths is attributed to increases in drug poisonings and was also observed in black and Latino young adults.

CONCLUSIONS AND RELEVANCE

Mortality rates in the United States have generally declined for infants and youths from 1999 to 2015 owing to reductions in sudden infant death syndrome, unintentional injury death, and homicides. However, US mortality rates remain higher than Canada and England/Wales, with particularly elevated rates among black and American Indian/Alaskan Native youth. Further, there is a concerning increase in suicide and drug poisoning death rates among US adolescents and young adults.

E-cigarettes and Tobacco Exposure Biomarkers among American Indian Smokers

Objective We assessed associations between electronic cigarette (e-cigarette) use and smoking-related measures among American Indians (AIs) who smoke. MethodsWe collected baseline survey and smoking biomarker data in a cohort of 375 adult AI smokers at a Cherokee Nation healthcare facility in Oklahoma. We used multivariate logistic and linear regression analyses to determine associations between e-cigarette use and smoking-related characteristics, including biomarkers. ResultsCurrent e-cigarette users were more likely than never users to report a quit attempt in the past 12 months (current vs never adjusted odds ratio (AOR) = 2.24 [95% CI 1.20-4.16]). Current and past e-cigarette users were more likely than never users to report a likelihood to quit smoking (current vs never AOR = 2.97 [95% CI 1.34-6.56]; past vs never AOR = 1.77 [95% CI 1.08-2.91]). E-cigarette use was not significantly associated with confidence to quit smoking, cigarette packs smoked per day, or cotinine levels. ConclusionsE-cigarette use was associated with previous and future quit attempts, but not with reductions in cigarette smoking or confidence in quitting. This suggests that many dual users might benefit from the addition of evidence-based smoking cessation treatments.

America's Declining Well-Being, Health, and Life Expectancy: Not Just a White Problem

Although recent declines in life expectancy among non-Hispanic Whites, coined "deaths of despair," grabbed the headlines of most major media outlets, this is neither a recent problem nor is it confined to Whites. The decline in America's health has been described in the public health literature for decades and has long been hypothesized to be attributable to an array of worsening psychosocial problems that are not specific to Whites. To test some of the dominant hypotheses, we show how various measures of despair have been increasing in the United States since 1980 and how these trends relate to changes in health and longevity. We show that mortality increases among Whites caused by the opioid epidemic come on the heels of the crack and HIV syndemic among Blacks. Both occurred on top of already higher mortality rates among all Americans relative to people in other nations, and both occurred among declines in measures of well-being. We believe that the attention given to Whites is distracting researchers and policymakers from much more serious, longer-term structural problems that affect all Americans.

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.

"Living off the Land": How Subsistence Promotes Well-Being and Resilience among Indigenous Peoples of the Southeastern United States

Indigenous peoples of the United States tend to experience the most severe social, behavioral, and physical health disparities of any ethnic minority. This critical ethnography uses the framework of historical oppression, resilience, and transcendence to examine indigenous peoples' perspectives on and experiences with subsistence living, investigating how subsistence living may contribute to well-being and resilience by promoting physical exercise, a healthy diet, and psychological health. Thematic analysis of data from 436 participants across two southeastern tribes reveals three overarching themes: fostering fond memories and family bonding through "living off the land," enabling experiential intergenerational teaching and learning, and promoting resourcefulness and offsetting economic marginalization. Results indicate that subsistence is an important avenue to promote sustainable and organic approaches to health and well-being within indigenous communities by facilitating positive nutrition and diet, exercise, and subjective well-being.

Understanding the social and community support networks of American Indian women cancer survivors

Cancer is the leading cause of death among American Indian and Alaska Native (AI/AN) women. Although cancer disparities among AI women are alarming, there is littlle research focused on the topic of social support and cancer treatment and outcomes. A community advisory board was used to develop and administer the project, and a qualitative descriptive study methodology was used. This research was conducted in partnership with two community-based hospitals in the Northern Plains. The sample included 43 AI female cancer survivors who were interviewed with a semi-structured interview guide. The data were analyzed using content analysis. Emergent themes revealed that AI cancer survivors' non-familial support systems included friends (n = 12), support groups (n = 6), churches (n = 10), co-workers (n = 5), communities (n = 4), support from health practitioners (n = 3), and additional forms of support. Results indicate that survivors' networks are diverse and support broad prevention programs that reach out to churches, community groups, and online forums. These sources of supports can be enhanced through sustainable community-based infrastructures.

Healthcare barriers and supports for American Indian women with cancer

Although American Indian (AI) women continue to experience cancer at higher rates and have not seen the same decline in cancer prevalence as the general U.S. population, little research examines how interactions with health care providers may influence and exacerbate these health disparities. The purpose of the study was to understand the experiences of AI women who receive cancer treatment, which is integral for eradication of AI cancer disparities among women. A qualitative descriptive methodology was used with a sample of 43 AI women with breast, cervical, colon, and other types of cancer from the Northern Plains region of South Dakota. Interviews were conducted from June 2014 to February 2015. Qualitative content analysis revealed that women experienced: (a) health concerns being ignored or overlooked; (b) lack of consistent and qualified providers; (c) inadequate healthcare infrastructure; (d) sub-optimal patient-healthcare provider relationships; (e) positive experiences with healthcare providers; and (f) pressure and misinformation about treatment. Results indicate the types of support AI women may need when accessing healthcare. Culturally informed trainings for healthcare professionals may be needed to provide high-quality and sensitive care for AI women who have cancer, and to support those providers already providing proper care.

Transnational Mortality Comparisons Between Archipelago and Mainland Puerto Ricans

Puerto Ricans in the US experience higher deaths from diabetes and other causes compared to non-Hispanic Whites and other Hispanic groups. We compared mortality in Puerto Rico to that of Puerto Ricans in the US as a first step to investigate if similar or worse mortality patterns originate from the sending country (Puerto Rico). Age-adjusted death rates were generated using national vital statistics databases in the US and territories for all-cause and the top ten causes of death among Hispanics in 2009. Mortality ratios in the archipelago of Puerto Rico (APR) were compared to mainland US Puerto Ricans (MPR). Rates for other ethnic/racial groups (Mexican Americans, Cubans, and non-Hispanic Whites, Blacks, American Indians, and Asians) were calculated to provide a context. APR had significantly higher all-cause mortality and death rates for diabetes, nephritis, pneumonia/influenza, and homicide/assault compared to MPR (APR/MPR ratio for all-cause: 1.08, diabetes: 2.04, nephritis: 1.84, pneumonia/influenza: 1.33, homicide/assault: 3.15). Death rates for diabetes and homicide/assault (particularly among men) were higher among APR compared to any other racial/ethnic groups in the US. In contrast, deaths from heart disease, cancer, and chronic liver disease were significantly lower for APR compared to MPR (MPR/APR ratio 0.72, 0.91, 0.41, respectively). Among APR women, death rates for these causes were also lower compared to any other group in the US. Substantial mortality variability exists between Puerto Ricans in Puerto Rico and those in the US, re-emphasizing the need to study of how socio-environmental determinants of health differ in sending and receiving countries. Explanations for disparate rates include access to and availability of healthcare and unique factors related to the migration experience of this group.

Prayer and Faith: Spiritual Coping among American Indian Women Cancer Survivors

Although cancer disparities among American Indian (AI) women are alarming, research on spiritual coping among this population is virtually nonexistent. This is particularly problematic, given the importance of medical practitioners' discussing the topic with cancer patients, along with the centrality of spirituality to many AI patients. The purpose of this article was to explore AI women cancer survivors' spiritual coping with their experiences. Using a community-based participatory research approach, this qualitative descriptive study included a sample of 43 AI women cancer survivors (n = 14 breast cancer, n = 14 cervical cancer, and n = 15 colon and other types of cancer). Qualitative content analysis revealed that most participants (76 percent, n = 32) cited prayer as an important part of their cancer recovery and coping strategies. Many participants expressed how prayer and spirituality connected them to family, to faith communities, and to others. In addition to prayer, over a third (36 percent, n = 15) of participants emphasized faith as a recovery and coping strategy. Results indicate that most women drew great comfort, strength, hope, and relief from their spiritual and faith traditions, indicating that religious and spiritual practices may be an important protective factor against the strain of the cancer experience.

Association between iq'mik smokeless tobacco use and cardiometabolic risk profile among Yup'ik Alaska Native people

OBJECTIVE

The traditional lifestyle of Yup'ik Alaska Native people, including a diet abundant in marine-based foods and physical activity, may be cardio-protective. However, iq'mik, a traditional form of smokeless tobacco used by >50% of Yup'ik adults, could increase cardiometabolic (CM) risk. Our objective was to characterize the associations between iq'mik use and biomarkers of CM status (low-density lipoprotein cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C], triglycerides [TG], systolic blood pressure [SBP] and diastolic blood pressure [DBP], glycated hemoglobin [HbA1c], fasting blood glucose [FBG], waist circumference [WC], and body mass index [BMI]).

DESIGN

We assessed these associations using data from a cross-sectional sample of Yup'ik adults (n = 874). Current iq'mik use, demographic, and lifestyle data were collected through interviews. Fasting blood samples were collected to measure LDL-C, HDL-C, TG, HbA1c, and FBG. SBP, DBP, WC, and BMI were obtained by physical examination. We characterized the association between current iq'mik use and continuous biomarkers of CM status using multiple approaches, including adjustment for measures of Yup'ik lifestyle and a propensity score.

RESULTS

Based on either adjustment method, current iq'mik use was significantly and positively associated with at least 5% higher HDL-C, and significantly associated but in an inverse direction with multiple biomarkers of CM status including 7% lower TG, 0.05% lower HbA1c, 2% lower FBG, 4% lower WC, and 4% lower BMI. Observed associations for LDL-C, SBP, and DBP varied by adjustment method.

CONCLUSIONS

This inverse association between iq'mik use and cardiometabolic risk status has not been previously reported. Additional research is needed to replicate these findings and explore physiological mechanisms and/or confounding factors.

Mortality disparities: A comparison with the Haudenosaunee in New York State

Identifying health status and disparities for Indigenous populations is the first logical step toward better health. We compare the mortality profile of the American Indian and Alaska Native (AI/AN) population with that of non-Hispanic whites in the Haudenosaunee Nations in New York State, the Indian Health Service (IHS) East region (Nashville Area) and the United States. Data from the linkage of IHS registration records with decedents from the National Death Index (1990-2009) were used to identify AI/AN deaths misclassified as non-AI/AN. Analyses were limited to persons of non-Hispanic origin. We analyzed trends for 1990-2009 and compared AI/AN and white persons in the Haudenosaunee Nations in New York State, IHS East region and the United States. All-cause death rates over the past two decades for Haudenosaunee men declined at a greater percentage per year than for AI/AN men in the East region and United States. This decrease was not observed for Haudenosaunee women with all-cause death rates appearing to be stable over the past two decades. Haudenosaunee all-cause death rates were 16% greater than that for whites in the Haudenosaunee Nations. The most prominent disparities between Haudenosaunee and whites are concentrated in the 25-44 year age group (Risk Ratio=1.85). Chronic liver disease, diabetes, unintentional injury, and kidney disease death rates were higher in Haudenosaunee than in whites in the Haudenosaunee Nations. The Haudenosaunee cancer death rate (180.8 per 100,000) was higher than that reported for AI/AN in the East (161.5 per 100,000).Haudenosaunee experienced higher rates for the majority of the leading causes of death than East AI/AN. These results highlight the importance of Haudenosaunee-specific data to target prevention efforts to address health disparities and inequalities in health.

"Improving Native American elder access to and use of health care through effective health system navigation"

BACKGROUND

Public insurance reforms of the past two decades have failed to substantively address the healthcare needs of American Indians in general, let alone the particular needs of American Indian elders, ages 55 years and older. Historically, this population is more likely to be uninsured and to suffer from greater morbidities, poorer health outcomes and quality of life, and lower life expectancies compared to all other United States aging populations, representing a neglected group within the healthcare system. Despite the pervasive belief that the Indian Health Service will address all their health-related needs, American Indian elders are negatively affected by gaps in insurance and lack of access to health care. While the 2010 Patient Protection and Affordable Care Act included provisions to ameliorate disparities for American Indians, its future is uncertain. In this context, American Indian elders with variable health literacy must navigate a complex and unstable healthcare system, regardless of where they seek care.

METHODS

This community-driven study features a mixed-method, participatory design to examine help-seeking behavior and healthcare experiences of American Indian elders in New Mexico, in order to develop and evaluate a tailored intervention to enhance knowledge of, access to, and use of insurance and available services to reduce healthcare disparities. This study includes qualitative and quantitative interviews combined with concept mapping and focus groups with American Indian elders and other key stakeholders.

DISCUSSION

The information gathered will generate new practical knowledge, grounded in actual perspectives of American Indian elders and other relevant stakeholders, to improve healthcare practices and policies for a population that has been largely excluded from national and state discussions of healthcare reform. Study data will inform development and evaluation of culturally tailored programming to enhance understanding and facilitate negotiation of the changing landscape of health care by American Indian elders. This work will fill a gap in research on public insurance initiatives, which do not typically focus on this population, and will offer a replicable model for enhancing the effects of such initiatives on other underserved groups affected by healthcare inequities.

TRIAL REGISTRATION

This protocol does not include the collection of health outcome data. Clinicaltrials.gov, NCT03550404 . Registered June 6, 2018.

Commentary: Will 'Deaths of Despair' among Whites Change How We Talk about Racial/Ethnic Health Disparities?

The recent trend of premature death among Whites in the United States has garnered attention in both the popular and academic literature. This attention has focused on the plight of low socioeconomic status Whites in non-urban areas. The population health literature in general and the health disparities literature more specifically has struggled to describe differences in health when White groups present worse health outcomes or worsening trends compared with racial/ethnic minority groups. There remain many open questions as population health/health disparities research attempts to explain the increasing mortality rates for low socioeconomic status Whites in non-urban areas in relationship to other racial/ethnic groups. As the conversation in the academic and popular literature continues to unfold, a key question for population health research and practice is how will the 'deaths of despair' phenomenon among Whites influence our measuring of, and reporting and intervening on, race/ethnic health disparities?