Talking Circles: Northern Plains Tribes American Indian Women's Views of Cancer as a Health Issue

"I Can Feel It in My Spine": Indigenous Women's Embodied Experiences of Violence and Healing

This article draws on the stories told by Indigenous women in the midwestern United States to explore embodied experiences of violence and how they conceptualize healing in the aftermath of violence. Two focus groups-conducted as talking circles-were completed with 16 Indigenous women. Findings highlight four salient themes: embodied impacts of violence; normalization of violence; (im)possibilities of healing; and strategies for healing. In particular, the women highlighted embodied practices like collective storytelling as a means of healing. This study deepens our understanding of violence against women by promoting Indigenous ways of knowing and uplifting the voices of Indigenous women.

Improving Breast Cancer Outcomes for Indigenous Women in Australia

In Australia, the incidence rate of breast cancer is lower in Indigenous* women than non-Indigenous women; however, the mortality rate is higher, with Indigenous women 1.2 times more likely to die from the disease. This paper provides practical and achievable solutions to improve health outcomes for Indigenous women with breast cancer in Australia. This research employed the Context-Mechanism-Outcome (CMO) framework to reveal potential mechanisms and contextual factors that influence breast cancer outcomes for Indigenous women, stratified into multiple levels, namely, micro (interpersonal), meso (systemic) and macro (policy) levels. The CMO framework allowed us to interpret evidence regarding Indigenous women and breast cancer and provides nine practical ways to improve health outcomes and survival rates.

Developing the Weaving Healthy Families Program to Promote Wellness and Prevent Substance Abuse and Violence: Approach, Adaptation, and Implementation

Family prevention programs that enhance mental health, wellness, and resilience-while simultaneously addressing violence and alcohol and other drug (AOD) abuse-among Indigenous families are scarce. This gap in culturally grounded and community-based programs creates a critical need to develop and evaluate the efficacy of such prevention programs. This article fills this gap, with the purpose of describing the structure and content of the Weaving Healthy Families (WHF) program, a culturally grounded and community-based program aimed at preventing violence and AOD use while promoting mental health, resilience, and wellness in Indigenous families. The focus then turns to how to approach this process of developing and implementing the program in a culturally grounded and community-based way.

A qualitative exploration of Indigenous patients' experiences of racism and perspectives on improving cultural safety within health care

BACKGROUND

In Canada, Indigenous Peoples continue to experience persistent health inequities, resulting in disproportionately poorer health outcomes compared with non-Indigenous Canadians. This study engaged Indigenous patients accessing health care in Vancouver, Canada, about their experiences of racism and improving cultural safety within health care.

METHODS

A research team consisting of Indigenous and non-Indigenous researchers committed to employing a Two-Eyed Seeing approach and conducting culturally safe research hosted 2 sharing circles in May 2019 with Indigenous people recruited from urban health care settings. Talking circles were led by Indigenous Elders, and thematic analysis was used to identify overarching themes.

RESULTS

A total of 26 participants attended 2 sharing circles, which included 25 self-identifying women and 1 self-identifying man. Thematic analysis resulted in the identification of 2 major themes: negative experiences in health care and perspectives on promising health care practices. For the first major theme, subthemes included the following: experiences of racism lead to poorer care experiences and health outcomes, Indigenous-specific racism results in mistrust in the health care system, and participants experience discrediting of traditional medicine and Indigenous perspectives on health. For the second major theme, subthemes included the following: Indigenous-specific services and supports improve trust in health care, Indigenous cultural safety education is necessary for all health care-involved staff, and providing welcoming, Indigenized spaces for Indigenous patients encourages health care engagement.

INTERPRETATION

Despite participants' racist health care experiences, receiving culturally safe care was credited with improving trust in the health care system and well-being. The continued expansion of Indigenous cultural safety education, the creation of welcoming spaces, recruitment of Indigenous staff, and Indigenous self-determination over health care services can improve Indigenous patients' health care experiences.

Comparison of Study Quality as Determined by Standard Research and Community Engagement Metrics: A Pilot Study on Breast Cancer Research in Urban, Rural, and Remote Indigenous Communities

The purpose of this review is to compare research evaluation tools to determine whether the tools typically used for assessing the quality of research adequately address issues of Indigenous health and culture, particularly when the studies are intended to benefit Indigenous peoples in urban, regional, rural, and remote settings. Our previously published systematic review evaluated studies about breast cancer using a modified Indigenous community engagement tool (CET). In this study, we evaluated the same studies using two commonly used tools: the Critical Appraisal Skills Programme (CASP) for qualitative research; and the Effective Public Health Practice Project (EPHPP) for quantitative research. The results were then compared to ascertain whether there was alignment between performances in terms of engagement and the CASP/EPHPP metrics. Of the 15 papers, 3 papers scored weakly on both metrics, and are therefore the least likely to offer reliable findings, while 2 papers scored strongly on both metrics, and are therefore the most likely to offer reliable findings. Beyond this summation, it was clear that the results did not align and, therefore, could not be used interchangeably when applied to research findings intended to benefit Indigenous peoples. There does not appear to be a pattern in the relationship between the reliability of the studies and the study settings. In order to address disparities in health outcomes, we must assess research through a typical research quality and cultural engagement and settings lens, ensuring that there is rigour in all aspects of the studies.

Assessing Social Determinants of Health in a Prenatal and Perinatal Cultural Intervention for American Indians and Alaska Natives

American Indians and Alaska Natives (AIANs) refer to cultural traditions and values to guide resilient and strength-based practices to address maternal and infant health disparities.

METHODS

A case study of a culturally-based educational intervention on AIAN maternal and child health.

RESULTS

Cultural teachings have successfully been applied in AIAN behavioral interventions using talking circles and cradleboards, but maternal and child health interventions are not well-represented in peer-reviewed literature. Zero publications included interventions centered around cradleboards and safe sleep.

DISCUSSION

There is a need for rigorous published research on culturally based interventions and effectiveness on health outcomes for mothers and babies.

CONCLUSIONS

This paper discusses how a cradleboard educational intervention incorporates national guidelines to address maternal and infant health while mediating social determinants of health.

Weaving Healthy Families Program: Promoting Resilience While Reducing Violence and Substance Use

PURPOSE

We examine pilot results for the culturally adapted Weaving Healthy Families (WHF) program to promote resilience and wellness while preventing substance abuse and violence among Native American (NA) families.

METHODS

Results were drawn from paired sample t tests and analyses of variance (ANOVA) with a convenience sample of 24 adults and adolescents from eight NA families (pretest, posttest, and, where available, 6-month postintervention).

RESULTS

Along with substance abuse reduction and prevention, t test results indicated reductions in (a) adult depressive symptoms and improvements in adult conflict resolution and health behaviors; (b) adolescent wellness; and (c) adult and adolescent resilience, communal mastery, social support, and sugar-sweetened beverage consumption. ANOVA tests revealed reductions in adult psychological and physical violence and improvements in adult and adolescent family resilience, family environment, and emotional regulation.

CONCLUSIONS

Results reveal promising preliminary results for the WHF program to promote resilience and thriving while reducing risk for substance abuse and violence in NA families.

What Is the Evidence Globally for Culturally Safe Strategies to Improve Breast Cancer Outcomes for Indigenous Women in High Income Countries? A Systematic Review

The aim was to systematically assess the evidence on whether cultural safety affects breast cancer outcomes with regards to care for Indigenous women in high income countries. We conducted a systematic review in accordance with PRISMA guidelines of peer-reviewed articles in Medline, EMBASE, CINAHL, Scopus, Web of Science, Proquest Sociology and Informit Rural health database and Indigenous collection databases. Key inclusion criteria were: adult female patients with breast cancer; high income country setting; outcome measure, including screening, diagnosis, treatment and follow up care. A total of 15 were selected. We developed a Community Engagement assessment tool in consultation with aboriginal researchers, based on the National Health and Medical Research Councils' community engagement guidelines, against which studies were appraised. This novel element allowed us to evaluate the literature from a new and highly relevant perspective. Thematic analysis of all 15 studies was also undertaken. Despite limited literature there are evidence-based strategies that are likely to improve outcomes for Indigenous women with breast cancer in high income countries and indicate that culture makes a positive difference. It is also clear that strong Indigenous community leadership and governance at all stages of the research including design is an imperative for feasibility.

A Systematic Literature Review of Cancer Communication with Indigenous Populations in Canada and the United States

Cancer is one of the leading causes of death among Indigenous populations. Communication campaigns are an important component of cancer prevention and treatment. However, communication about cancer with Indigenous populations has yet to be fully explored and understood. In this systematic literature review, we examine peer-reviewed research to gain insight into the factors that contribute to effective communication about cancer with Indigenous populations. The review yielded a total of 7313 potential articles and a total of 25 of these manuscripts met the inclusion criteria. Results indicate five primary factors that may increase the effectiveness of communication about cancer with Indigenous populations. Factors include the need to (1) respect traditional knowledge, (2) use appropriate language, (3) involve community members in the communication process, (4) include people from different generations in message design, and (5) engender trust in health communicators. Results also provide insight into communication methods that contribute to effective cancer communication. We identify gaps in the literature and provide recommendations for future cancer communication strategies and research with Indigenous populations.

Quantification of Potential Inequities in Breast Cancer Incidence in New Mexico Through Bayesian Disease Mapping

INTRODUCTION

The incidence of breast cancer among non-Hispanic American Indian and Alaska Native (AI/AN) women varies across the United States. We applied county-level Bayesian disease mapping to quantify potential inequities in 10-year breast cancer incidence in New Mexico to better inform health equity initiatives among its non-Hispanic at-risk AI/AN population.

METHODS

We used data from the Surveillance, Epidemiology, and End Results (SEER) program from 2005 through 2014 to identify new cases of breast cancer in New Mexico's 33 counties. To account for spatial variation, a county-level Area Deprivation Index, and the small area estimation problem inherent in these data, we borrowed strength globally and locally by applying Bayesian disease mapping to the counts of age-adjusted county-level breast cancer incidence. We quantified the disparity effect, as measured by the age-adjusted rate ratio, comparing the incidence of breast cancer between at-risk non-Hispanic AI/AN and non-Hispanic White women and assessed whether the ratio differed among counties.

RESULTS

Accounting for over-dispersion and spatial correlation among the 33 counties and a county-level Area Deprivation Index, the posterior mean of the overall age-adjusted rate ratio was 0.384 (95% credible interval, 0.253--0.546). The age-adjusted rate of breast cancer in non-Hispanic AI/AN women was 0.38 times the corresponding age-adjusted rate for non-Hispanic White women; however, a significant reduction in breast cancer incidence was observed in 16 of the 33 counties.

CONCLUSION

The application of Bayesian disease mapping to these data provided substantial evidence of an overall disparity in breast cancer incidence between at-risk non-Hispanic AI/AN and non-Hispanic White women in New Mexico, which was more marked than previously reported and limited to certain counties. Targeted statewide and county-level health-equity initiatives may lead to a reduction in these disparities.

American Indian women cancer survivors' perceptions and experiences with conventional and non-conventional mental health care for depressive symptoms

Background: Despite cancer and depression being disproportionately high for American Indian and Alaska Native (AI/AN) women, such cancer survivors' help-seeking practices and perceptions related to depression are absent in extant research. A broader context of historical oppression has set the stage for unequal health outcomes and access to quality services. The purpose of this article was to explore AI women cancer survivors' experiences with conventional mental health services and informal and tribally-based assistance, as well as barriers related to mental health service utilization.Methods: A qualitative descriptive study methodology, with qualitative content analysis, was used to examine the experiences of AI women cancer survivors as they related to help-seeking experiences for depressive symptoms. The sample included 43 AI women cancer survivors (n = 14 breast cancer, n = 14 cervical cancer, and n = 15 colon and other types of cancer survivors).Results: Since receiving a cancer diagnosis, 26 (62%) participants indicated they had feelings of depression. Some participants (n = 13) described mixed perceptions of the mental health service system. Generally, participants viewed families and informal support systems as primary forms of assistance, whereas conventional services were reported as a supplementary or 'as needed' forms of support, particularly when the informal support system was lacking. Participants received help in the forms of psychotropic medications and psychotherapy, as well as help from family and AI-specific healing modalities (e.g. sweat lodges and healing ceremonies). Stigma and confidentiality concerns were primary barriers to utilizing conventional services as described by 12 (29%) participants.Discussion: Participants' help primarily came from family and tribally-based entities, with conventional mental health care being more salient when informal supports were lacking. The mixed perceptions espoused by participants may be related to a broader context of historical oppression; family and social support and tribally-based services may be protective factors for cancer survivors with depression.

Family: The Bedrock of Support for American Indian Women Cancer Survivors

Cancer disparities among American Indian (AI) women are alarming, yet a dearth of research focuses on the role of family support for such women. The purpose of this research was to examine the composition of AI women cancer survivors' family support networks and the types of support that they provided. We used a qualitative descriptive methodology with 43 AI women cancer survivors and qualitative content analysis, which indicated that 38 participants (approximately 90%) reported that their families provided integral and varied forms of support, especially instrumental support throughout cancer experiences. Families were the bedrock of support for AI women cancer survivors.

Indigenous Australian women's experiences of participation in cervical screening

Aboriginal and Torres Strait Islander (collectively, Indigenous Australian) women experience a higher burden of cervical cancer than other women. The National Cervical Screening Program (NCSP) is failing to meet the needs of Indigenous Australian women, resulting in many women not regularly participating in cervical screening. However, one third of Indigenous Australian women do participate in cervical screening. The reasons that some women in this population commence and continue to screen remain unheard but could provide insights to support women who currently do not participate. We aimed to describe Indigenous Australian women’s experiences and views of participation in cervical screening by yarning (a culturally-appropriate interview technique) with 50 Indigenous Australian women aged 25–70 years who had completed cervical screening in the past five years, recruited via Primary Health Care Centres (PHCCs) from three jurisdictions. Aboriginal or Torres Strait Islander women researchers conducted the interviews. Thematic analysis identified six themes: screening as a means of staying strong and in control; overcoming fears, shame, and negative experiences of screening; needing to talk openly about screening; the value of trusting relationships with screening providers; logistical barriers; and overcoming privacy concerns for women employed at PHCCs. Despite describing screening as shameful, invasive, and uncomfortable, women perceived it as a way of staying healthy and exerting control over their health. This ultimately supported their participation and a sense of empowerment. Women valued open discussion about screening and strong relationships with health providers. We identified logistical barriers and specific barriers faced by women employed at PHCCs. This study is strengthened by a research approach that centred Indigenous Australian women’s voices. Understanding the experiences of Indigenous Australian women who participate in screening will help screening providers support women to start and continue to screen regularly. Recommendations for practice are provided.

Formative Research and Cultural Tailoring of a Substance Abuse Prevention Program for American Indian Youth: Findings From the Intertribal Talking Circle Intervention

Background. Substance use among American Indians (AIs) is a critical health issue and accounts for many health problems such as chronic liver disease, cirrhosis, behavioral health conditions, homicide, suicide, and motor vehicle accidents. In 2013, the highest rates of substance use and dependence were seen among AIs when compared to all other population groups, although these rates vary across different tribes. Among AI adolescents, high rates of substance use have been associated with environmental and historical factors, including poverty, historical trauma, bicultural stress, and changing tribal/familial roles. Our project, the Intertribal Talking Circle intervention, involved adapting, tailoring, implementing, and evaluating an existing intervention for AI youth of three tribal communities in the United States. Formative Results. Community partnership committees (CPCs) identified alcohol, marijuana, and prescription medications as high priority substances. CPC concerns focused on the increasing substance use in their communities and the corresponding negative impacts on families, stating a lack of coping skills, positive role models, and hope for the future as concerns for youth. Cultural Tailoring Process Results. Each site formed a CPC that culturally tailored the intervention for their tribal community. This included translating Keetoowah-Cherokee language, cultural practices, and symbolism into the local tribal customs for relevance. The CPCs were essential for incorporating local context and perceived concerns around AI adolescent substance use. These results may be helpful to other tribal communities developing/implementing substance use prevention interventions for AI youth. It is critical that Indigenous cultures and local context be factored into such programs.

Perspectives on restoring health shared by Cree women, Alberta, Canada

The purpose of this study was to explore nehiyaw iskwêwak (Cree women's) perceptions and beliefs about how to restore balance to health. Fifteen indigenous women from Northern Alberta, Canada, participated in a 3-day cultural retreat on beauty and art in British Columbia, Canada, in May 2015. At the end of the retreat, these women were invited to participate in a talking circle and asked, 'What does restoring balance look like?' A constructivist grounded theory approach was used to explore individual and collective perspectives on restoring health. Nehiyaw iskwêwak provided a vision of health using metaphors from the natural environment. Starting points and core characteristics of health were grounded in relationship with self, others, place and the land, suggesting interventions grounded in land-based pedagogy and focused on restoring relationship and secure attachment might be effective for this population. Nehiyaw iskwêwak also said interventions should start at the individual level; as the individual restores balance mentally, emotionally, physically and spiritually, a long-term ripple effect can be initiated through the generations and community when these women in turn support the strengthening and nurturing of relations (e.g. parents, siblings, friends, children, grandchildren) for the next seven generations.

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.

Developing a patient-reported experience questionnaire with and for people who use drugs: A community engagement process in Vancouver's Downtown Eastside

People who use drugs (PWUD) frequently have complex health care needs, yet face multiple barriers to accessing services. Involving PWUD in health service design and evaluation can enhance the quality of data collected and ensure policy and practice improvements reflect the expressed needs of the population. However, PWUD remain largely excluded from the evaluation of health services that directly affect their lives, including development of patient-reported experience measures (PREMS) that have gained prominence in health services research and clinical practice. Detailed descriptions of PWUD participation in survey design are notably absent in the literature. In this commentary, we present a case that demonstrates how PWUD can contribute meaningfully to the development of questionnaires that assess patient-reported health care experiences. We describe the development, implementation and outcomes of a process to engage local drug user organizations in the evaluation of a redesign and reorientation of health service delivery in the Downtown Eastside (DTES) neighborhood of Vancouver, Canada. Through this process, participants contributed critical elements to the design of a patient-reported experience measure, including: (1) identifying unmet service needs in the neighborhood; (2) identifying local barriers and facilitators to care; (3) formulating questions on cultural safety; and (4) improving structure, language and clarity of the questionnaire. We highlight lessons learned from the process, reflecting on the strengths, challenges and ethical considerations associated with community-based approaches to questionnaire development. The workshop model presented here illustrates one flexible and promising approach to enabling meaningful participation of PWUD in questionnaire development.

Thinking Differently in Global Health in Oncology Using a Diagonal Approach: Harnessing Similarities, Improving Education, and Empowering an Alternative Oncology Workforce

Cancer is a leading global cause of death, and diverse and minority populations suffer worse outcomes compared with white people from Western societies. Within the United States, African Americans and other blacks, Hispanics, Asians, and American Indians have lower cancer survival rates than whites. In the rest of the world, those from low- and middle-income countries have the greatest disparities, but even those from non-Western high-income countries such as Oman and the United Arab Emirates are diagnosed with cancer at later stages and suffer increased mortality. Although considerable differences exist among these populations, similarities and synergies are also apparent. Challenges can be very similar in reaching these populations effectively for cancer control to improve outcomes, and innovative strategies are needed to effectively make change. In this review, the authors discuss new approaches to the prevention and early detection of cancer as well as the implementation of programs in global oncology and put in evidence cultural similarities and challenges of different populations, highlighting strategies to improve cancer survival and quality care around the world through innovations in training and education, empowerment of an alternative workforce, and a diagonal approach to cancer care using case studies drawn from the authors' work and experience.

The Design of a Multi-component Intervention to Promote Screening Mammography in an American Indian Community: The Native Women's Health Project

BACKGROUND

Breast cancer is an important public health issue among American Indian/Alaska Native (AI/AN) women in the US. This article describes the design and implementation of a culturally sensitive intervention to promote breast health among AI/AN women through a hybrid model that incorporates clinical and community-based approaches. This is one of the first studies using this model addressing breast cancer disparities among AI/AN populations in the US.

METHODS

The Theory of Planned Behavior was used as the guiding framework of the intervention and Community Based Participatory Research was the primary vehicle for the intervention planning and implementation. Three preliminary studies took place that aimed to identify qualitatively and quantitatively what deterred or encouraged AI women to get past or future mammograms. The research results were shared with community members who, through a prioritization process, identified the theoretical focus of the intervention and its corresponding activities. The priority population consisted of AI women ages 40-74, with no recent mammogram, and no breast cancer history.

RESULTS

The intervention centered on the promotion of social modeling and physician recommendation. The main corresponding activities included enhancing patient-physician communication about screening mammography through a structured dialogue, receipt of a breast cancer brochure, participation in an inter-generational discussion group, and a congratulatory bracelet upon receipt of a mammogram. Environmental and policy related changes also were developed.

CONCLUSION

Creating a theory-based, culturally-sensitive intervention through tribal participatory research is a challenging approach towards eliminating breast cancer disparities among hard-to-reach populations.

Family and Friend Influence on Urban-Dwelling American Indian Adolescent Girl's Sexual Risk Behavior

Previous research with American Indian (AI) adolescent sexual risk behavior primarily focused on reservation-dwelling youth despite 70% of AIs living off Native lands. Using grounded theory methodology, I sampled 20 adolescent AI girls via talking circles and interviews to explore the perceptions of AI adolescent girls living in an urban, Midwest area about the influence of family and friends on their sexual behavior. Similar to research with other racial groups, participants cited their family and friends as a major influence. Five unique themes emerged related to family and friend influence. Urban-dwelling AI girls rely on their female family members and peers for information related to sex and receive varying messages from their networks of family and friends, which often overlap. AI youth have unique family groups yet have some similarities to other ethnic groups with regard to family and friend relationships that may allow for enhanced intervention development.

Development and evaluation of an enhanced diabetes prevention program with psychosocial support for urban American Indians and Alaska natives: A randomized controlled trial

Diabetes is highly prevalent, affecting over 25 million adults in the US, yet it can be effectively prevented through lifestyle interventions, including the well-tested Diabetes Prevention Program (DPP). American Indian/Alaska Native (AIAN) adults, the majority of whom live in urban settings, are more than twice as likely to develop diabetes as non-Hispanic whites. Additionally, prevalent mental health issues and psychosocial stressors may facilitate progression to diabetes and hinder successful implementation of lifestyle interventions for AIAN adults. This 2-phased study first engaged community stakeholders to develop culturally-tailored strategies to address mental health concerns and psychosocial stressors. Pilot testing (completed) refined those strategies that increase engagement in an enhanced DPP for urban AIAN adults. Second, the enhanced DPP will be compared to a standard DPP in a randomized controlled trial (ongoing) with a primary outcome of body mass index (BMI) and a secondary outcome of quality of life (QoL) over 12months. Obese self-identified AIAN adults residing in an urban setting with one or more components of the metabolic syndrome (excluding waist circumference) will be randomized to the enhanced or standard DPP (n=204). We hypothesize that addressing psychosocial barriers within a culturally-tailored DPP will result in clinical (BMI) and superior patient-centered (QoL) outcomes as compared to a standard DPP. Exploratory outcomes will include cardiometabolic risk factors (e.g., waist circumference, blood pressure, fasting glucose) and health behaviors (e.g., diet, physical activity). Results of this trial may be applicable to other urban AIAN or minority communities or even diabetes prevention in general.

American Indian elders share personal stories of alcohol use with younger tribal members

In this Great Lakes Indian reservation qualitative study we utilized focus groups in the form of talking circles to elicit tribal members' views of alcohol use. We report on how the elder participants utilized the talking circles to inform the youth of the deleterious effects of alcohol use and abuse. Indigenous research methods were utilized so elder tribal members were consulted about the study; an elder was hired as a research associate; youth were hired as note takers/observers; and the 2-hour groups were led by a tribal community member. Demographic data were gathered, and a semistructured guide with substance use questions was utilized. Tribal members, 30 females and 19 males, age 12 to 78 participated in 8 talking circles (N = 49). Tribal elders unexpectedly utilized the format as an opportunity for cross-generational storytelling to convey their own oral histories of the harmful effects of alcohol use for the younger participants. They shared personal pathways to quitting or to a reduction in drinking with messages aimed at preventing the youth from initiating drinking. A shortage of American Indian (AI) substance abuse treatment programs that are culturally relevant exists. The widespread and renewed use of cross-generational talking circles could serve as an inexpensive substance abuse prevention and intervention treatment modality for AI youth. The elders' stories highlight the need to rejuvenate traditional methods of healing among AIs to reduce the initiation and/or harmful effects of overuse of alcohol among AI youth.

An Analysis of Health Behavior Theories Applied to Breast-Screening Behavior for Relevance With American Indian Women

This article reviews studies of the efficacy of breast-screening interventions and their related theories that have had a positive effect in influencing women to use mammography and assesses the potential of various behavioral models for use with American Indian women. The study involved a search of literature in nursing and other health fields. Both communityand practice-based interventions have incorporated elements of various theoretical models. Because of its adaptability, the modified health behavior model appears most relevant for designing interventions to encourage mammography use among American Indian women.

Correlates of Receipt of Colorectal Cancer Screening among American Indians in the Northern Plains

Research has consistently documented lower colorectal cancer (CRC) screening rates for racial and ethnic minority populations, with the lowest screening rates among American Indians (AIs). Given the low CRC screening rates among AIs residing in the Northern Plains region, the objective of this research was to identify CRC screening correlates for Northern Plains AIs. With a sample of 181 AIs age 50 years or older, the authors used Andersen's behavioral model to examine the following factors related to receipt of CRC screening: (a) predisposing factors-age, education, marital status, and gender; (b) need factors-personal and family history of cancer; and (c) enabling factors-having a particular place to receive medical care, annual health checkup, awareness of the availability of CRC screening, knowledge of CRC, and self-efficacy of CRC. Nested logistic regression identified the following correlates of receipt of CRC screening: (a) predisposing factors-older age; (b) need factors-having a personal history of cancer; and (c) enabling factors-having an annual health checkup, greater awareness of CRC screening, and greater self-efficacy of CRC. Given the findings, prevention and intervention strategies, including public awareness and education about CRC screening, are promising avenues to reduce cancer screening disparities among AIs.

The Experience of Cancer in American Indians Living in Oklahoma

Many cancers in American Indians (AIs) are not diagnosed early leading to effects on physical, social, and emotional well-being or quality of life (QOL). Little research has been done on QOL of AIs in Oklahoma. This study examined the experience of living with cancer of AIs in Oklahoma to gain greater understanding of QOL issues and provide a basis for interventions to improve QOL. Twenty AIs diagnosed with cancer and receiving care in Oklahoma participated in this pilot study through semistructured interviews. Data were analyzed using thematic analysis. Themes identified included circles of support, finding meaning in the experience, and facing personal challenges such as health care-related issues, including mental health needs and fragmented care. The findings from this pilot study provide insights into the cancer experience of AIs in Oklahoma and demonstrate that care navigation and social support are important aspects to address in intervention development.

Predictors of regular mammography use among American Indian women in Oklahoma: a cross-sectional study

Background

There are significant disparities in breast cancer screening and survivorship between American Indian (AI) and non-Hispanic white women. This study aimed to identify the salient beliefs AI women from Oklahoma have on regular mammography screening, and to determine which beliefs and health- related practices are associated with past mammography screening behavior.

Methods

This study used an integrated model of the Theory of Planned Behavior as the guiding theoretical framework. Data were collected from 255 (mean age = 51 years, SD 7.64 years) AI women randomly selected from a rural Oklahoma medical clinic (response rate: 79%). Multivariate logistic regression was used to identify factors associated with self-reported past mammography within the last two years while controlling for demographic variables. Associations were summarized using odds ratios (OR), the ratio of the odds of past mammography per a 1-unit increase in continuous independent factor scales (subjective physician norm, cultural affiliation, fatalism, knowledge of mammography screening guidelines, and perceived behavior control barriers) or between groups defined by categorical variables, and 95% confidence intervals (CI).

Results

Of the participants, 65% (n = 167) reported a screening mammogram within the last two years. After adjustment for age and educational status, women with a higher total subjective-norm physician score (OR = 1.15, 95% CI: 1.06-1.24), a higher knowledge of mammography screening guidelines (OR = 1.52, 95% CI: 1.00-2.31), a family history of breast cancer (OR = 9.97, 95% CI: 3.05-32.62), or reporting an annual versus none or a single physician breast examination (OR = 5.57, 95% CI: 1.79-17.37) had a higher odds of past mammography. On the other hand, women who were more culturally affiliated (OR = 0.42, 95% CI: 0.24-0.74), perceived more barriers (OR = 0.86, 0.78-0.94), or had higher fatalistic attitudes toward breast cancer (OR = 0.90, 95% CI: 0.82-0.99) had lower odds of past mammography.

Conclusion

In the development of culturally-appropriate interventions promoting mammography among AI communities, emphasis could be put on the following: a) promoting clinic-related practices (e.g. physician recommendation, physician breast examination); b) promoting community-related practices (e.g. knowledge about mammography while eliminating fatalistic attitudes); and c) reducing environmental barriers.

Urban Dwelling American Indian Adolescent Girls' Beliefs Regarding Health Care Access and Trust

Indigenous people, specifically American Indians (AI), have historically had a greater mistrust of the medical system compared to their White counterparts. The purpose of this paper is to explore the perceptions of AI adolescent girls living in an urban, Midwest area about health care providers, health care systems, and access to health care as related to sexual health care. Using grounded theory methodology, twenty 15-19 year old AI girls participated in talking circles and individual interviews. Two distinct themes emerged related to sexual health care: 1) AI adolescent girls trust their health care providers and the health care system; and 2) Access to health care is critical to practicing safe sex and obtaining information about healthy sexual practices. These findings are unique and may help health care providers and social workers providing care and support to the urban adolescent AI girl.

Urban American Indian Adolescent Girls: Framing Sexual Risk Behavior

PURPOSE

The purpose of this study was to explore factors that influence urban adolescent American Indian (AI) girls' sexual risk behavior.

DESIGN

A qualitative study was conducted with grounded theory methodology to reveal factors and processes that influence sexual risk behavior.

METHOD

Talking circles, individual interviews, and event history calendars were used with 20 urban AI 15- to 19-year-old girls to explore influences on sexual risk behavior.

RESULTS

The generated theory-framing sexual risk behavior-describes social and structural factors and processes that influenced the girls' sexual risk behavior. The theory extends Bronfenbrenner's ecological model by identifying microsystem, mesosystem, and macrosystem influences on sexual risk behavior.

DISCUSSION

Urban AI girls reported similar social and structural influences on sexual risk behavior as urban adolescents from other racial and ethnic groups. However, differences were noted in the family structure, cultural heritage, and unique history of AIs.

IMPLICATIONS

This theory can be used in culturally responsive practice with urban AI girls.

Assessment of mammography experiences and satisfaction among American Indian/Alaska Native women

BACKGROUND

American Indian/Alaska Native (AI/AN) women have lower breast cancer (BCA) screening and 5-year survival rates than non-Hispanic Whites. Understanding reasons for low screening rates is important to combatting later stage diagnoses. The purpose of this study was to assess mammography experiences and satisfaction among AI/AN women.

METHODS

Nine focus groups were held with rural (N = 15) and urban (N = 38) AI/AN women 40 years and older in Kansas and Kansas City, Missouri, living both near and far from Indian Health Service (IHS) and tribal facilities, to examine experiences and satisfaction with mammography. Transcripts were coded and themes identified using a community-based participatory research approach.

FINDINGS

Themes were classified under knowledge, communication, and awareness of BCA; barriers to mammography; mammogram facility size; impressions of mammogram technologist; motivations for getting a mammogram; and how to improve the mammogram experience. Participants had knowledge of prevention, but described cultural reasons for not discussing it and described better experiences in smaller facilities. Participants indicated having a mammogram technologist who was friendly, knowledgeable, respectful, competent, and explained the test was a determining factor in satisfaction. Other factors included family history, physician recommendation, and financial incentives. Barriers included transportation, cost, perceptions of prejudice, and time constraints. Participants on reservations or near IHS facilities preferred IHS over mainstream providers. Suggestions for improvement included caring technologists, better machines with less discomfort, and education.

CONCLUSIONS

Interventions to enhance the professionalism, empathy, and cultural awareness of mammogram technologists; reduce barriers; and provide positive expectations and incentives could improve satisfaction and compliance with screening mammography.

Development of culturally tailored educational brochures on HPV and pap tests for American Indian women

PURPOSE

Participatory formative research guided the creation of a culturally tailored educational brochure about human papillomavirus (HPV) at an American Indian women's clinic.

METHOD

A review of existing educational materials and in-depth interviews were conducted. Nine steps for creating health communications messages that were patterned after National Cancer Institute guidelines guided the brochure development process.

RESULTS

Of 95 women tested for HPV, 41% were positive, 32 (34%) agreed to the in-depth interview, and 9 agreed to the pretesting interview. Mean age was 41 years. Interviews revealed key themes concerning emotional reactions to abnormal Pap test results and HPV; need for basic information about HPV, Pap tests, and results; concerns about HPV stigma, sexual transmission, and communication with sexual partner; and the preferred source and format for HPV educational materials. A literature review revealed 12 areas of basic HPV content.

CONCLUSIONS

A participatory process successfully engaged nursing staff and patients in creating culturally appropriate brochures for clinic use.

IMPLICATIONS

This article provides specific steps for creating culturally tailored patient education materials.

Mammography adherence: a qualitative study

BACKGROUND

Regular mammography accounts for half of the recent declines in breast cancer mortality. Mammography use declined significantly in 2008. Given the success of regular breast cancer screening, understanding why mammography use decreased is important. We undertook a focus group study to explore reasons women who were previously adherent with regular mammography no longer were screened.

METHODS

We conducted 20 focus groups with white non-Hispanic, black non-Hispanic, Hispanic, Japanese American, and American Indian/Alaska Native women, and segmented the groups by age, race/ethnicity, and health insurance status. A conceptual framework, based on existing research, informed the development of the focus group guide. Discussion topics included previous mammography experiences, perceptions of personal breast cancer risk, barriers to mammography, and risks and benefits associated with undergoing mammography. Atlas.ti was used to facilitate data analysis.

RESULTS

All focus groups (n=128 women) were completed in 2009 in five cities across the United States. Half of the groups were held with white non-Hispanic women and the remainder with other racial/ethnic groups. Major barriers to routine mammography included (1) concerns about test efficacy, (2) personal concerns about the procedure, (3) access to screening services, (4) psychosocial issues, and (5) cultural factors. For uninsured women, lack of health insurance was the primary barrier to mammography.

CONCLUSIONS

Multilevel interventions at the health-care provider and system levels are needed to address barriers women experience to undergoing regular mammography screening. Ultimately, breast cancer screening with mammography is an individual behavior; therefore, individual behavioral change strategies will continue to be needed.

OxyContin misuse on a reservation: qualitative reports by American Indians in talking circles

Few studies have addressed OxyContin use among American Indians (AIs) on reservations. Eight focus groups were conducted as "talking circles" (2006 and 2007 ) with 49 AI adults and youth. An emergent design was utilized in which the initial two circles were planned, but the subsequent six circles evolved from tribal members' input. Participants reported an increase in OxyContin use; negative effects on individuals, families, and the tribe; a lack of treatment options; and a growing problem on other reservations. Results indicate the need to further research prevalence and patterns of use to design interventions to curtail OxyContin abuse on reservations.

Intention to receive cancer screening in Native Americans from the Northern Plains

BACKGROUND

Native Americans are disproportionately affected by cancer morbidity and mortality. This study examined intention to receive cancer screening in a large sample of Native Americans from the Northern Plains, a region with high cancer mortality rates.

METHODS

A survey was administered orally to 975 individuals in 2004-2006 from three reservations and among the urban Native American community in the service region of the Rapid City Regional Hospital. Data analysis was conducted in 2009.

RESULTS

About 63% of the sample planned to receive cancer screening. In multivariate analyses, individuals who planned to receive cancer screening were women, responsible for four or more people, received physical examinations at least yearly and had received prior cancer screening. They also were more likely to hold the belief that most people would go through cancer treatment even though these treatments can be emotionally or physically uncomfortable. About 90% of those who did not plan to receive cancer screening would be more likely to intend to receive cancer screening if additional resources were available.

CONCLUSIONS

In an area of high cancer morbidity and mortality, over one-third of screening eligible individuals did not plan to receive cancer screening. Future research should evaluate the potential for improving cancer screening rates through interventions that seek to facilitate increased knowledge about cancer screening and access to cancer screening services in the community.

Cultural context of school communities in rural Hawaii to inform youth violence prevention

BACKGROUND

Escalation of youth violence within a large geographic school-complex area in southeastern rural Hawaii became a major problem in 2006. How cultural forces impact the problem was an impetus to examine youth violence from perspectives of adults and children in rural communities. Gathering these data was an essential first step toward school-based youth violence prevention program development.

METHODS

Eight focus groups involving 86 community stakeholders included 51 adults (parent, teachers, school staff, community leaders) and 35 children aged 8-15 years old (3rd- to 10-th grade). Qualitative narrative analysis elicited major themes.

RESULTS

Five themes emerged: (1) School-community violence takes on many forms that become entrenched in local culture. (2) Disintegration of community resources and a sense of learned helplessness underlie the escalation of youth violence. (3) Inadequate role modeling coupled with behavioral ambivalence among adults has sustained a climate of local cultural acceptance with youth violence. (4) Connection to cultural values has diminished, leading to a sense of loss in cultural identity among students. (5) Cultural values and practices are potential strategies for youth violence prevention.

CONCLUSIONS

Cultural and community contextual factors contributed to youth violence in rural Hawaiian communities. Study implications include the need to further investigate the impact of vigilant, community involvement of stakeholders in school-based youth violence prevention program development. Cultural revitalization at family, school, and community levels may be critical success factors of such programs.

Near misses: paradoxical realities in everyday clinical practice

This qualitative study was conducted to define and describe what constitutes and contributes to near miss occurrences in the health-care system and what is needed to ensure safer processes of care. Nine health-care organizations (13 sites total) including six academic health sciences centres (acute care, mental health and geriatric) and three community hospitals participated in this study. The final sample consisted of 37 focus groups (86 in the nursing staff only; 62 in the pharmacy staff only; and 99 in the mixed nursing and pharmacy focus groups respectively) and 120 interviews involving 144 health-care consumers. Data were collected using focus groups (health-care professionals) and key informant interviews (health-care consumers). A multi-level content analyses schema (transcription, coding, categorizing, internal consistency, thematic analysis and community validation) was used. Six themes emerged from the multi-level content analyses that combined focus group (health-care professionals) and key informant interview (health-care consumers) data. These themes are discussed under the three original research questions with supporting data derived from codes and categories. Study findings implicate changes for the health-care landscape relative to system, health policy, professional development and quality improvement.

Native Teen Voices: adolescent pregnancy prevention recommendations

PURPOSE

American Indian adolescent pregnancy rates are high, yet little is known about how Native youth view primary pregnancy prevention. The aim was to identify pregnancy prevention strategies from the perspectives of both male and female urban Native youth to inform program development.

METHODS

Native Teen Voices (NTV) was a community-based participatory action research study in Minneapolis and St. Paul, Minnesota. Twenty focus groups were held with 148 Native youth who had never been involved in a pregnancy. Groups were stratified by age (13-15 and 16-18 years) and sex. Participants were asked what they would do to prevent adolescent pregnancy if they were in charge of programs for Native youth. Content analyses were used to identify and categorize the range and types of participants' recommendations within and across the age and sex cohorts.

RESULTS

Participants in all cohorts emphasized the following themes: show the consequences of adolescent pregnancy; enhance and develop more pregnancy prevention programs for Native youth in schools and community-based organizations; improve access to contraceptives; discuss teen pregnancy with Native youth; and use key messages and media to reach Native youth.

CONCLUSIONS

Native youth perceived limited access to comprehensive pregnancy prevention education, community-based programs and contraceptives. They suggested a variety of venues and mechanisms to address gaps in sexual health services and emphasized enhancing school-based resources and involving knowledgeable Native peers and elders in school and community-based adolescent pregnancy prevention initiatives. A few recommendations varied by age and sex, consistent with differences in cognitive and emotional development.

Talk-story: perspectives of children, parents, and community leaders on community violence in rural Hawaii

PURPOSE

To enhance our understanding of what community violence means to a multiethnic school community in rural Hawaii and obtain people's perspectives of how to deal with and prevent violence-related behaviors among children.

DESIGN AND SAMPLE

An exploratory design was used to collect qualitative data from a purposive sample of 150 key stakeholder participants, including 84 school children aged 5-10 years and 66 adults.

MEASUREMENT

Focus group methodology via Hawaiian island-style (culturally adapted techniques) of "talk-story" and a metaphor of introduction were used to elicit contextual data on the experiences, meanings, and perceptions of youth violence. Qualitative narrative analyses were used to analyze the data.

RESULTS

Five higher order themes were found, including the need to: build a common understanding of what violence looks like; develop school-based identification, management, and prevention efforts; develop comprehensive school health services; develop state-level school health policies; and conduct outreach to make violence prevention a community affair.

CONCLUSION

The findings will inform the development of a school-based culturally adapted violence-prevention program led by teachers, in partnership with parents, students, and community-cultural leaders.