Community-based participatory research in Indian country: improving health through water quality research and awareness

Perception of the local community: What is their relationship with environmental quality indicators of reservoirs?

Evaluating the conservation of aquatic ecosystems, especially those which serve to supply, has been carried out using a variety of tools. However, the perception of water quality by the local community which lives in direct contact with water resources has not been considered with enough importance. This study analysed the relationship between the conservation status of reservoirs as perceived by the local community and their conservation status according to physical, chemical, and biological indicators. To do so, we calculated the Trophic State Index (TSI) of the reservoirs, the diversity and richness of benthic macroinvertebrate and we analysed the human influence in the riparian zone. Thus, we created the Community Conservation Perception Index (CCPI) to quantitatively associate the perception of the local community with environmental quality indicators (TSI, diversity, richness and anthropogenic influences in the riparian zone). We found that interviewee perception of reservoir conservation (using the CCPI) was related to trophic state, richness and diversity of benthic macroinvertebrate, and the presence of residences and agriculture in the riparian zone. It is necessary to consider the environmental perception of the local community as a relevant factor in management programmes and the conservation of ecosystems, even if artificial, as is the case with reservoirs. These communities can significantly contribute to maintaining the environmental quality through their performance in participatory management in projects such as: participating in the investigation of pollution in reservoirs, collecting parameters related to water quality, and community action in designing conservation strategies.

Participatory Research for Environmental Justice: A Critical Interpretive Synthesis

BACKGROUND

Environmental health risks are disproportionately colocated with communities in poverty and communities of color. In some cases, participatory research projects have effectively addressed structural causes of health risk in environmental justice (EJ) communities. However, many such projects fail to catalyze change at a structural level.

OBJECTIVES

This review employs Critical Interpretive Synthesis (CIS) to theorize specific elements of participatory research for environmental health that effectively prompt structural change in EJ communities.

METHODS

Academic database search was used to identify peer-reviewed literature describing participatory research with EJ communities to address environmental health. Synthetic constructs were developed iteratively related to study characteristics, design elements, and outcomes; and data were extracted for included records. Statistical analyses were performed to assess correlations between study design elements and structural change outcomes. Through critical, comparative, and contextual analyses of the "structural change" case study group and "non- structural change" group, informed by relevant theoretical literature, a synthesizing argument was generated.

RESULTS

From 505 total records identified, eligibility screening produced 232 case study articles, representing 154 case studies, and 55 theoretical articles for synthesis. Twenty-six case studies resulted in a structural change outcome. The synthesizing argument states that participatory research with EJ communities may be more likely to result in structural change when a) community members hold formal leadership roles; b) project design includes decision-makers and policy goals; and c) long term partnerships are sustained through multiple funding mechanisms. The assumption of EJ community benefit through research participation is critically examined.

DISCUSSION

Recommended future directions include establishing structural change as a goal of participatory research, employing participatory assessment of community benefit, and increased hiring of faculty of color at research institutions. The power, privilege, and political influence that academic institutions are able to leverage in partnership with EJ communities may be as valuable as the research itself. https://doi.org/10.1289/EHP6274.

Our Relationship to Water and Experience of Water Insecurity among Apsáalooke (Crow Indian) People, Montana

Affordable access to safe drinking water is essential to community health, yet there is limited understanding of water insecurity among Native Americans. Therefore, the focus of this paper is to describe Apsáalooke (Crow Indian) tribal members' experiences with water insecurity. For Apsáalooke people, local rivers and springs are still vitally important for traditional cultural activities. We interviewed 30 Native American adults living on the Crow Reservation in Southeastern Montana. Participants answered six open-ended interview questions about their water access, costs of obtaining water and changes in their domestic and traditional water uses. Participants emphasized how the use of water has changed over time and described the complex challenges associated with addressing water insecurity in their community, including the importance of considering the spiritual and cultural impacts of water insecurity on health. Water insecurity is a growing global problem and more attention and efforts are needed to find appropriate and affordable solutions.

An interview project with native American people: a community-based study to identify actionable steps to reduce health disparities

OBJECTIVES

The primary objective of this study was to work with tribal communities to define and develop their own healthcare services and strategies for positive change regarding injection drug use, human immunodeficiency virus (HIV), and hepatitis C virus (HCV) infection. The secondary objective of this study was to incorporate community capacity building strategies to develop and sustain programming and resources to optimize tribal communities' responsiveness to reduce health disparities.

STUDY DESIGN

Semi-structured qualitative interviews.

METHODS

Interviews were guided by community-based participatory research (CBPR) principles to create programs, projects, and policy recommendations meaningful to American Indian and Alaska Native (AI/AN) people.

RESULTS

The study generated a formative understanding of the context of AI/AN people who inject drugs (PWID) in three distinct AI/AN communities as well as developed local capacity for future programming, projects, and policy.

CONCLUSIONS

This study confirms CBPR methods should be part of an iterative cycle to inform policy and programs. CBPR has helped strengthen local research capacity and has formed ongoing relationships between study investigators, local liaisons, and the community that will be essential for next phases of program design and policy implementation. This cycle of CBPR could be replicated in other tribal communities to bring awareness of the opioid epidemic and its effects and to prioritize local indigenous and community-led responses.

Developing a Curriculum for Change: Water and Environmental Health Literacy in a Native American Community

BACKGROUND

Knowing about risks of water contamination is the first step in making informed choices to protect our health and environment. Researchers were challenged with sharing water quality research this information with local communities.

OBJECTIVES

The purpose of this article is to describe the formative evaluation used to develop and implement an Environmental Health Literacy (EHL) summer camp and afterschool water curriculum for Native American (NA) children in the fourth through sixth grades.

METHODS

Community and university scientists, elders, and educators came together and co-developed a summer camp and afterschool program for local youth to address the issues of water and its importance to the tribal community.

LESSONS LEARNED

Research partners must continually balance research needs with relationships and service to the community. The health literacy framework used to develop our curriculum also complemented our community-based participatory research (CBPR) approach and may benefit other partnerships. CBPR helped to build trust and culturally center the intervention.

CONCLUSIONS

Project partners built on the mutual commitment to "do what we say we will do" within the community context. Using the CBPR approach provided a strong framework for the collaboration necessary for this project. Trust relationships were key to the successes experienced during the development, implementation, and multiple revisions of this intervention.

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.

Metagenomic Profiling of Microbial Pathogens in the Little Bighorn River, Montana

The Little Bighorn River is the primary source of water for water treatment plants serving the local Crow Agency population, and has special significance in the spiritual and ceremonial life of the Crow tribe. Unfortunately, the watershed suffers from impaired water quality, with high counts of fecal coliform bacteria routinely measured during run-off events. A metagenomic analysis was carried out to identify potential pathogens in the river water. The Oxford Nanopore MinION platform was used to sequence DNA in near real time to identify both uncultured and a coliform-enriched culture of microbes collected from a popular summer swimming area of the Little Bighorn River. Sequences were analyzed using CosmosID bioinformatics and, in agreement with previous studies, enterohemorrhagic and enteropathogenic Escherichia coli and other E. coli pathotypes were identified. Noteworthy was detection and identification of enteroaggregative E. coli O104:H4 and Vibrio cholerae serotype O1 El Tor, however, cholera toxin genes were not identified. Other pathogenic microbes, as well as virulence genes and antimicrobial resistance markers, were also identified and characterized by metagenomic analyses. It is concluded that metagenomics provides a useful and potentially routine tool for identifying in an in-depth manner microbial contamination of waterways and, thereby, protecting public health.

The Strong Heart Water Study: Informing and designing a multi-level intervention to reduce arsenic exposure among private well users in Great Plains Indian Nations

Elevated arsenic exposure from drinking water is associated with an increased risk of cardiovascular disease, diabetes, kidney disease, and skin, lung, and bladder cancer. Arsenic contamination in groundwater supplies disproportionately affects rural populations using private wells. Arsenic mitigation programs for American Indian communities are limited. There is an urgent need for targeted approaches to reduce arsenic exposure for at-risk communities using private wells. Formative research was conducted to inform and design a community-based arsenic mitigation intervention for Lakota and Dakota Nations in the Great Plains Area of the United States, where, in some communities, one-quarter of private wells are estimated to have elevated arsenic. Formative research included semi-structured interviews, a community workshop, intervention-planning workshops, and a pilot study of the developed intervention. Community members prioritize aesthetic qualities of water (e.g. taste, color), safety, and other situational factors (e.g. cost) when considering their drinking and cooking water. Although water safety is a concern, awareness and concern for arsenic vary substantially within communities. To reduce arsenic exposure, community members recommended communication of water test results, home visits for intervention delivery, and reminders to use arsenic-safe water. Findings informed the development of an intervention to prevent arsenic exposure through drinking water and cooking, including health promotion messages and household items to facilitate use of an arsenic removal device (e.g. tankards to store filtered water). The pilot study indicated promising acceptability and operability of the developed intervention. This research provides a model for the development of environmental health interventions in partnership with American Indian and other private well-using communities.

Expanding Environmental Health Literacy-A Focus on Water Quality and Tribal Lands

Environmental health literacy (EHL), an evolving concept, has potential for significant public health impact. However, complex skills are needed to access and use information, to study and document hazards, to link findings to health outcomes, and to understand the complexities of regulations and laws needed to take efficacious action. Because water issues are creating headlines world-wide, we draw from several water-related cases on American Indian tribal lands to examine some of the complexities associated with building needed skills, obtaining accessible information, and navigating the layers of laws and regulations that enable or inhibit efficacious action. Each case highlights the importance of partnerships, skill building, and collaborative action to redress environmental assaults. For our analysis, we draw from and expand upon Nutbeam's typology of health literacy which includes functional, interactive, and critical stages to derive lessons from each of the EHL cases. Community partnerships engaging in EHL efforts still face many challenges, including enhancing skills for community members as well as professionals, clarifying scientific processes and findings, articulating and respecting cultural practices and needs, and translating policies and laws for community accessibility and collaborative action.

Guardians of the Living Water: Using a Health Literacy Framework to Evaluate a Child as Change Agent Intervention

BACKGROUND

American Indian communities in the United States experience considerable health inequities, including increased exposure to environmental contaminants. Consequently, community members of the Apsáalooke (Crow) Nation identified the lack of water-related environmental knowledge among children as an area of concern.

AIM

The purpose of this study was to provide a feasibility evaluation of an increasingly sophisticated environmental health literacy program for children.

METHOD

A community-academic partnership developed and piloted the Guardians of the Living Water program to increase environmental health literacy among children and their families on the Crow reservation. Nutbeam's framework for health literacy, a schema based on functional, interactive, and critical literacy, shaped the program evaluation. We used a within-subjects, quasi-experimental design without a control group. Interviews with children and parents were used to assess the feasibility of the program, while pre-/posttests assessed changes in knowledge, skills, and behavior.

RESULTS

Compared with preintervention responses, those from postintervention indicated significant increases for selected knowledge and attitude components. Based on qualitative interviews with children and caregivers, the camp was a valuable experience and increased knowledge of water quality science and reinforced cultural knowledge.

DISCUSSION

This success of our program stems from the trust initially built between partners and then expanded throughout the community. The program and the evaluation benefited from both the health literacy framework and from our integration of Apsáalooke values.

CONCLUSION

Our findings suggest that a community-based intervention designed to increase environmental health literacy among youth and their social networks is feasible and acceptable to this American Indian community.

Detection of Pathogenic and Non-pathogenic Bacteria in Drinking Water and Associated Biofilms on the Crow Reservation, Montana, USA

Private residences in rural areas with water systems that are not adequately regulated, monitored, and updated could have drinking water that poses a health risk. To investigate water quality on the Crow Reservation in Montana, water and biofilm samples were collected from 57 public buildings and private residences served by either treated municipal or individual groundwater well systems. Bacteriological quality was assessed including detection of fecal coliform bacteria and heterotrophic plate count (HPC) as well as three potentially pathogenic bacterial genera, Mycobacterium, Legionella, and Helicobacter. All three target genera were detected in drinking water systems on the Crow Reservation. Species detected included the opportunistic and frank pathogens Mycobacterium avium, Mycobacterium gordonae, Mycobacterium flavescens, Legionella pneumophila, and Helicobacter pylori. Additionally, there was an association between HPC bacteria and the presence of Mycobacterium and Legionella but not the presence of Helicobacter. This research has shown that groundwater and municipal drinking water systems on the Crow Reservation can harbor potential bacterial pathogens.

A Perspective on the Global Pandemic of Waterborne Disease

Waterborne diseases continue to take a heavy toll on the global community, with developing nations, and particularly young children carrying most of the burden of morbidity and mortality. Starting with the historical context, this article explores some of the reasons why this burden continues today, despite our advances in public health over the past century or so. While molecular biology has revolutionized our abilities to define the ecosystems and etiologies of waterborne pathogens, control remains elusive. Lack of basic hygiene and sanitation, and failing infrastructure, remain two of the greatest challenges in the global fight against waterborne disease. Emerging risks continue to be the specter of multiple drug resistance and the ease with which determinants of virulence appear to be transmitted between strains of pathogens, both within and outside the human host.

Perceived versus actual water quality: Community studies in rural Oaxaca, Mexico

Compromised water quality risks public health, which becomes particularly acute in economically marginalized communities. Although the majority of the clean-water-deprived population resides in Sub-Saharan Africa and Asia, a significant portion (32 million) lives in Meso- and Latin-America. Oaxaca is one of the marginalized southern states of Mexico, which has experienced high morbidity from infectious diseases and also has suffered from a high rate of infant mortality. However, there has been a paucity of reports on the status of water quality of culturally diverse rural Oaxaca. This study follows community-based participatory research methods to address the data gap by reporting on water quality (chemical and microbiological) and by exploring social realities and water use practices within and among communities. Surveys and water quality analyses were conducted on 73 households in three rural communities, which were selected based on the choice of water sources (i.e., river water, groundwater, and spring water). Statistically significant variations among communities were observed including the sanitation infrastructure (p-value 0.001), public perception on water quality (p-value 0.007), and actual microbiological quality of water (p-value 0.001). Results indicate a high prevalence of diarrheal diseases, a desire to improve water quality and reduce the cost of water, and a need for education on water quality and health in all the surveyed communities. The complexities among the three studied communities highlight the need for undertaking appropriate policies and water treatment solutions.

Challenges and Opportunities for Tribal Waters: Addressing Disparities in Safe Public Drinking Water on the Crow Reservation in Montana, USA

Disparities in access to safe public drinking water are increasingly being recognized as contributing to health disparities and environmental injustice for vulnerable communities in the United States. As the Co-Directors of the Apsaálooke Water and Wastewater Authority (AWWWA) for the Crow Tribe, with our academic partners, we present here the multiple and complex challenges we have addressed in improving and maintaining tribal water and wastewater infrastructure, including the identification of diverse funding sources for infrastructure construction, the need for many kinds of specialized expertise and long-term stability of project personnel, ratepayer difficulty in paying for services, an ongoing legacy of inadequate infrastructure planning, and lack of water quality research capacity. As a tribal entity, the AWWWA faces additional challenges, including the complex jurisdictional issues affecting all phases of our work, lack of authority to create water districts, and additional legal and regulatory gaps-especially with regards to environmental protection. Despite these obstacles, the AWWWA and Crow Tribe have successfully upgraded much of the local water and wastewater infrastructure. We find that ensuring safe public drinking water for tribal and other disadvantaged U.S. communities will require comprehensive, community-engaged approaches across a broad range of stakeholders to successfully address these complex legal, regulatory, policy, community capacity, and financial challenges.

Community Engaged Cumulative Risk Assessment of Exposure to Inorganic Well Water Contaminants, Crow Reservation, Montana

An estimated 11 million people in the US have home wells with unsafe levels of hazardous metals and nitrate. The national scope of the health risk from consuming this water has not been assessed as home wells are largely unregulated and data on well water treatment and consumption are lacking. Here, we assessed health risks from consumption of contaminated well water on the Crow Reservation by conducting a community-engaged, cumulative risk assessment. Well water testing, surveys and interviews were used to collect data on contaminant concentrations, water treatment methods, well water consumption, and well and septic system protection and maintenance practices. Additive Hazard Index calculations show that the water in more than 39% of wells is unsafe due to uranium, manganese, nitrate, zinc and/or arsenic. Most families' financial resources are limited, and 95% of participants do not employ water treatment technologies. Despite widespread high total dissolved solids, poor taste and odor, 80% of families consume their well water. Lack of environmental health literacy about well water safety, pre-existing health conditions and limited environmental enforcement also contribute to vulnerability. Ensuring access to safe drinking water and providing accompanying education are urgent public health priorities for Crow and other rural US families with low environmental health literacy and limited financial resources.

Community-based research as a mechanism to reduce environmental health disparities in american Indian and alaska native communities

Racial and ethnic minority communities, including American Indian and Alaska Natives, have been disproportionately impacted by environmental pollution and contamination. This includes siting and location of point sources of pollution, legacies of contamination of drinking and recreational water, and mining, military and agricultural impacts. As a result, both quantity and quality of culturally important subsistence resources are diminished, contributing to poor nutrition and obesity, and overall reductions in quality of life and life expectancy. Climate change is adding to these impacts on Native American communities, variably causing drought, increased flooding and forced relocation affecting tribal water resources, traditional foods, forests and forest resources, and tribal health. This article will highlight several extramural research projects supported by the United States Environmental Protection Agency (USEPA) Science to Achieve Results (STAR) tribal environmental research grants as a mechanism to address the environmental health inequities and disparities faced by tribal communities. The tribal research portfolio has focused on addressing tribal environmental health risks through community based participatory research. Specifically, the STAR research program was developed under the premise that tribal populations may be at an increased risk for environmentally-induced diseases as a result of unique subsistence and traditional practices of the tribes and Alaska Native villages, community activities, occupations and customs, and/or environmental releases that significantly and disproportionately impact tribal lands. Through a series of case studies, this article will demonstrate how grantees—tribal community leaders and members and academic collaborators—have been addressing these complex environmental concerns by developing capacity, expertise and tools through community-engaged research.

Detection and source tracking of Escherichia coli, harboring intimin and Shiga toxin genes, isolated from the Little Bighorn River, Montana

The Little Bighorn River flows through the Crow Indian Reservation in Montana. In 2008, Escherichia coli concentrations as high as 7179 MPN/100 ml were detected in the river at the Crow Agency Water Treatment Plant intake site. During 2008, 2009, and 2012, 10 different serotypes of E. coli, including O157:H7, harboring both intimin and Shiga toxin genes were isolated from a popular swim site of the Little Bighorn River in Crow Agency. As part of a microbial source tracking study, E. coli strains were isolated from river samples as well as from manure collected from a large cattle feeding operation in the upper Little Bighorn River watershed; 23% of 167 isolates of E. coli obtained from the manure tested positive for the intimin gene. Among these manure isolates, 19 were identified as O156:H8, matching the serotype of an isolate collected from a river sampling site close to the cattle feeding area.

"Exploring Effects of Climate Change on Northern Plains American Indian Health"

American Indians have unique vulnerabilities to the impacts of climate change because of the links among ecosystems, cultural practices, and public health, but also as a result of limited resources available to address infrastructure needs. On the Crow Reservation in south-central Montana, a Northern Plains American Indian Reservation, there are community concerns about the consequences of climate change impacts for community health and local ecosystems. Observations made by Tribal Elders about decreasing annual snowfall and milder winter temperatures over the 20^th century initiated an investigation of local climate and hydrologic data by the Tribal College. The resulting analysis of meteorological data confirmed the decline in annual snowfall and an increase in frost free days. In addition, the data show a shift in precipitation from winter to early spring and a significant increase in days exceeding 90° F (32° C). Streamflow data show a long-term trend of declining discharge. Elders noted that the changes are affecting fish distribution within local streams and plant species which provide subsistence foods. Concerns about warmer summer temperatures also include heat exposure during outdoor ceremonies that involve days of fasting without food or water. Additional community concerns about the effects of climate change include increasing flood frequency and fire severity, as well as declining water quality. The authors call for local research to understand and document current effects and project future impacts as a basis for planning adaptive strategies.

Applying indigenous community-based participatory research principles to partnership development in health disparities research

This case study of community and university research partnerships utilizes previously developed principles for conducting research in the context of Native American communities to consider how partners understand and apply the principles in developing community-based participatory research partnerships to reduce health disparities. The 7 partnership projects are coordinated through a National Institutes of Health-funded center and involve a variety of tribal members, including both health care professionals and lay persons and native and nonnative university researchers. This article provides detailed examples of how these principles are applied to the projects and discusses the overarching and interrelated emergent themes of sharing power and building trust.

Navigating International, Interdisciplinary, and Indigenous Collaborative Inquiry: Phase 1 in the Circumpolar Indigenous Pathways to Adulthood Project

This report describes how multiple community constituents came together to work with university researchers on developing a shared agenda for studying young indigenous people in five international circumpolar communities. The paper focuses on the set up and process of an initial face-to-face methodological planning workshop involving youth and adult community members and academics. Members of Yup'ik, Inupiat, Eveny, Inuit and Sámi communities from Siberia to Norway participated in the workshop and engaged in negotiations to arrive at shared research interests. This was essential since the ultimate goal of the research is translational and transformative, spurring social action in communities. Describing the beginning stage of this project and the underlying participatory methodology offers reader insight into the how the approach engaged community members with varying degrees of sustained interest and practical success. It, therefore, articulates a methodological approach for those interested in doing community-based participatory research in international contexts.

Community-based participatory research (CBPR) approach to study children's health in China: experiences and reflections

BACKGROUND

Community-based participatory research principles have been successfully applied to public health research in U.S. settings. While there is a long history of collaboration between government and communities in China, to date, community-based participatory research has not been used in children's environmental health studies.

METHOD

This article describes how community-based participatory research principles were applied by an international research group to the China Jintan Child Cohort Study, a longitudinal study of malnutrition and lead exposure on cognitive and neurobehavioral development. Challenges emerged and lessons learned from implementing the study were discussed and recommendations were presented.

CONCLUSION

We conclude that the community-based participatory research model can be applied in conducting and promoting environmental health research in China and researchers should be prepared for special challenges and cultural constraints in the implementation of the research in regards to human subject regulations, information dissemination, and culture.