Identifying and Reducing Disparities in Mental Health Outcomes Among American Indians and Alaskan Natives Using Public Health, Mental Healthcare and Legal Perspectives

Racial-Ethnic Differences in Receipt of Past-Year Health Care Services Among Suicide Decedents: A Case-Control Study

OBJECTIVE

Suicide remains an urgent public health crisis. Although some sociodemographic characteristics are associated with greater suicide risk in the general population, it is unclear whether individuals utilizing health care in the United States have similar suicide incidence patterns. The authors examined whether race-ethnicity is associated with suicide death among patients seeking health care and investigated health care utilization patterns.

METHODS

Data were collected from electronic health records and government mortality records for patients seeking health care across nine health care systems in the United States. Patients who died by suicide (N=1,935) were matched with patients in a control group (N=19,350) within each health care system.

RESULTS

Patients who died by suicide were significantly more likely to be White, older, male, living in low-education areas, living in rural areas, or diagnosed as having mental health conditions or were significantly less likely to have commercial insurance (p<0.05). Among most racial-ethnic groups, those who died by suicide had a higher number of past-year mental health, primary care, and total health care visits; for American Indian/Alaska Native patients, the number of health care visits tended to be lower among suicide decedents.

CONCLUSIONS

These findings suggest that higher past-year health care utilization was associated with increased likelihood of suicide death across several racial-ethnic groups. This observation underscores the need for identifying and managing suicide risk in health care settings, including outside of mental health visits, among most racial-ethnic groups.

Suicides among American Indian/Alaska Native firefighters: Data from the National Violent Death Reporting System, 2003 - 2017

Suicide is a significant public health problem in the United States and disproportionally affects male American Indian/Alaska Natives (AI/AN). Suicide is particularly problematic among AI/AN firefighters who are more likely to report suicide ideation, planning, attempts, and risk compared to non-Hispanic white (NHW) firefighters. The aim of the current study was to compare non-Hispanic AI/AN firefighter and NHW firefighter suicide decedents by demographics and risk/precipitating factors using National Violent Death Reporting System data for 45 male non-Hispanic AI/AN firefighter and 588 male NHW firefighter decedents who died by suicide. Compared to NHW firefighter decedents, AI/AN firefighter decedents were significantly younger and had significantly higher odds of experiencing alcohol use problems and a recent death/suicide of a family member/friend. AI/AN firefighter decedents had significantly lower odds of documented mental health problems, documented diagnosis of depression/dysthymia, receipt of mental health treatment, or leaving a suicide note compared to NHW firefighter decedents. Results from this study may inform tailored suicide prevention and screening efforts among first responders with the goal of lowering suicide mortality among AI/AN firefighters and fire service as a whole.

How Funding Policy Maintains Structural Inequity Within Indigenous Community-Based Organizations

Despite efforts to increase investment in Indigenous health and well-being in the United States, disparities remain. The way in which health-promoting organizations are funded is one key mechanism driving the systemic, long-term health disparities experienced by Indigenous people in the US. Using Indigenous-led community-based organizations (ICBOs) that provide psychosocial care as a case study, we highlight multiple ways in which policies that regulate the external funding that ICBOs depend on must change to promote equity and allow the organizations to flourish and address unmet psychosocial needs for Indigenous community members. We use a system dynamics approach to discuss how "capability traps" arise from a misfit between external funding regulations and organizations' needs for sustainability and effective care provision. We provide suggestions for reforming funding policies that focus on improving ICBO sustainability.

Evaluation of the Risk Identification for Suicide and Enhanced Care Model in a Native American Community

Importance

There are many prognostic models of suicide risk, but few have been prospectively evaluated, and none has been developed specifically for Native American populations.

Objective

To prospectively validate a statistical risk model implemented in a community setting and evaluate whether use of this model was associated with improved reach of evidence-based care and reduced subsequent suicide-related behavior among high-risk individuals.

Design, Setting, and Participants

This prognostic study, done in partnership with the White Mountain Apache Tribe, used data collected by the Apache Celebrating Life program for adults aged 25 years or older identified as at risk for suicide and/or self-harm from January 1, 2017, through August 31, 2022. Data were divided into 2 cohorts: (1) individuals and suicide-related events from the period prior to suicide risk alerts being active (February 29, 2020) and (2) individuals and events from the time after alerts were activated.

Main Outcomes and Measures

Aim 1 focused on a prospective validation of the risk model in cohort 1. Aim 2 compared the odds of repeated suicide-related events and the reach of brief contact interventions among high-risk cases between cohort 2 and cohort 1.

Results

Across both cohorts, a total of 400 individuals identified as at risk for suicide and/or self-harm (mean [SD] age, 36.5 [10.3] years; 210 females [52.5%]) had 781 suicide-related events. Cohort 1 included 256 individuals with index events prior to active notifications. Most index events (134 [52.5%]) were for binge substance use, followed by 101 (39.6%) for suicidal ideation, 28 (11.0%) for a suicide attempt, and 10 (3.9%) for self-injury. Among these individuals, 102 (39.5%) had subsequent suicidal behaviors. In cohort 1, the majority (220 [86.3%]) were classified as low risk, and 35 individuals (13.3%) were classified as high risk for suicidal attempt or death in the 12 months after their index event. Cohort 2 included 144 individuals with index events after notifications were activated. For aim 1, those classified as high risk had a greater odds of subsequent suicide-related events compared with those classified as low risk (odds ratio [OR], 3.47; 95% CI, 1.53-7.86; P = .003; area under the receiver operating characteristic curve, 0.65). For aim 2, which included 57 individuals classified as high risk across both cohorts, during the time when alerts were inactive, high-risk individuals were more likely to have subsequent suicidal behaviors compared with when alerts were active (OR, 9.14; 95% CI, 1.85-45.29; P = .007). Before the active alerts, only 1 of 35 (2.9%) individuals classified as high risk received a wellness check; after the alerts were activated, 11 of 22 (50.0%) individuals classified as high risk received 1 or more wellness checks.

Conclusions and Relevance

This study showed that a statistical model and associated care system developed in partnership with the White Mountain Apache Tribe enhanced identification of individuals at high risk for suicide and was associated with a reduced risk for subsequent suicidal behaviors and increased reach of care.

Traditional Ceremonial Practices as a Strategy to Reduce Problem Substance Use in American Indian Communities: A Systematic Review

Objective: This systematic review assessed the feasibility of American Indian traditional ceremonial practices (TCPs) to address problem substance use in both reservation and urban settings. Methods: Between September 24, 2021, and January 14, 2022, culturally specific review protocols were applied to articles retrieved from over 160 electronic databases-including PubMed, Global Health, Global Health Archive, CINAHL Complete, PsychInfo, Web of Science, Health and Wellness (Gale), Sage Online Journals, and ScienceDirect. Results: A total of 10 studies met the criteria for inclusion in the review. Studies were conducted with both urban (n = 7) and reservation (n = 3) American Indian and Alaska Native (AIAN) populations. The most common TCP activities reported were drumming (n = 9), sweat lodge (n = 7), and talking circles (n = 6). All 10 studies reported some type of quantitative data showing a reduction of substance use associated with TCP interventions or activities. Conclusions: The current status of the literature is emerging and does not allow for meta-analysis of existing studies. However, the existing literature does indicate promise for the use of TCPs to address problem substance use in AIAN communities in a way that is effective and also culturally congruent.

The Indian Health Service and American Indian/Alaska Native Health Outcomes

The Indian Health Service (IHS) has made huge strides in narrowing health disparities between American Indian and Alaska Native (AI/AN) populations and other racial and ethnic groups. Yet, health disparities experienced by AI/AN people persist, with deep historical roots combined with present-day challenges. Here we review the history of the IHS from colonization to the present-day system, highlight persistent disparities in AI/AN health and health care, and discuss six key present-day challenges: inadequate funding, limited human resources, challenges associated with transitioning services from federal to Tribal control through contracting and compacting, evolving federal and state programs, the need for culturally sensitive services, and the promise and challenges of health technology.

Journey to Promoting Structural Change for Chronic Disease Prevention: Examining the Processes for Developing Policy, Systems, and Environmental Supports in Native American Nations

Background

Obesity and chronic disease rates continue to be disproportionally high among Native Americans (NAs) compared with the US general population. Policy, systems, and environmental (PSE) changes can address the root causes of these health inequalities by supporting access to healthy food and physical activity resources.

Objective

We aim to describe the actors and processes involved in developing PSE changes supporting obesity prevention in NA Nations.

Methods

As part of the Obesity Prevention Research and Evaluation of InterVention Effectiveness in NaTive North Americans 2 (OPREVENT2) trial (ClinicalTrials.gov registration: NCT02803853), we collected 46 in-depth interviews, 1 modified Talking Circle, 2 workshops, and 14 observations in 3 NA communities in the Midwest and Southwest regions of the United States. Participants included Tribal government representatives/staff, health staff/board members, store managers/staff, and school administrators/staff. We used a Grounded Theory analysis protocol to develop themes and conceptual framework based on our data.

Results

Health staff members were influential in identifying and developing PSE changes when there was a strong relationship between the Tribal Council and health department leaders. We found that Tribal Council members looked to health staff for their expertise and were involved in the approval and endorsement of PSE changes. Tribal grant writers worked across departments to leverage existing initiatives, funding, and approvals to achieve PSE changes. Participants emphasized that community engagement was a necessary input for developing PSE changes, suggesting an important role for grassroots collaboration with community members and staff. Relevant contextual factors impacting the PSE change development included historical trauma, perspectives of policy, and "tribal politics".

Conclusions

This article is the first to produce a conceptual framework using 3 different NA communities, which is an important gap to be addressed if structural changes are to be explored and enacted to promote NA health. The journey to change for these NA Nations provides insights for promoting future PSE change among NA Nations and communities.

Increasing culturally responsive care and mental health equity with indigenous community mental health workers

There are 600 diverse American Indian/Alaska Native communities that represent strong and resilient nations throughout Indian Country. However, a history of genocidal practices, cultural assaults, and continuing oppression contribute to high rates of mental health and substance use disorders. Underresourced mental health care and numerous barriers to services maintain these disparities. Indigenous community mental health workers hold local understandings of history, culture, and traditional views of health and wellness and may reduce barriers to care while promoting tribal health and economic self-determination and sovereignty. The combination of Native community mental health workers alongside a growing workforce of Indigenous mental health professionals may create an ideal system in which tribal communities are empowered to restore balance and overall wellness, aligning with Native worldviews and healing traditions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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.

Self-Determination in Health Research: An Alaska Native Example of Tribal Ownership and Research Regulation

Alaska Native (AN) and American Indian (AI) people are underrepresented in health research, yet many decline to participate in studies due to past researcher misconduct. Southcentral Foundation (SCF), an Alaska Native-owned and operated health care organization, is transforming the relationship between researchers and the tribal community by making trust and accountability required features of health research in AN/AI communities. In 1998, SCF assumed ownership from the federal government of health services for AN/AI people in south central Alaska and transformed the health system into a relationship-based model of care. This change reimagines how researchers interact with tribal communities and established community oversight of all health research conducted with AN/AI people in the region. We describe the SCF research review process, which requires tribal approval of the research concept, full proposal, and dissemination products, as well as local institutional review board approval, and a researcher-signed contract. This review evaluates research through the lens of tribal principles, practices, and priorities. The SCF example provides a framework for other tribes and organizations seeking to reshape the future of health research in AN/AI communities.