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

Physical Pain Among Urban Native American Emerging Adults: Sociocultural Risk and Protective Factors

OBJECTIVE

American Indian/Alaska Native (AI/AN) people have high rates of physical pain. Pain is understudied in urban-dwelling, AI/AN emerging adults, a group with unique sociocultural risk and protective factors. We explore associations between socioeconomic disadvantage, additional sociocultural factors, and pain among urban AI/AN emerging adults.

METHODS

AI/AN participants aged 18-25 years ( N = 417) were recruited via social media. Regression models tested associations between socioeconomic disadvantage (income and ability to afford health care) and pain as well as additional sociocultural factors (discrimination, historical loss, cultural pride and belonging, visiting tribal lands) and pain. Multigroup regression models tested whether associations between sociocultural factors and pain differed between participants who were socioeconomically disadvantaged and those who were less disadvantaged.

RESULTS

In the full sample, lower income ( b = 1.00-1.48, p < .05), inability to afford health care ( b = 1.00, p = .011), discrimination ( b = 0.12, p = .001), and historical loss ( b = 0.24, p = .006) were positively associated with pain, whereas visiting tribal lands was negatively associated with pain ( b = -0.86 to -0.42, p < .05). In the multigroup model, visiting tribal lands 31+ days was negatively associated with pain only among the less socioeconomically disadvantaged group ( b = -1.48, p < .001).

CONCLUSIONS

Socioeconomic disadvantage may, in part, drive pain disparities among AI/AN emerging adults and act as a barrier to benefitting from visiting tribal lands. Results support a biopsychosocial approach to targeting pain in this population, including addressing socioeconomic challenges and developing culturally informed, strengths-based interventions.

Impact of In-Home Handwashing Stations on Hand Hygiene During the COVID-19 Pandemic in Unpiped Rural Alaska Native Homes

OBJECTIVES

More than 3300 rural Alaska Native homes lack piped water, impeding hand hygiene. During the COVID-19 pandemic, the Alaska Native Tribal Health Consortium and the Centers for Disease Control and Prevention partnered with 10 Tribal communities and regional Tribal health organizations to install a low-cost, intermediate-technology water and sanitation system, the Miniature Portable Alternative Sanitation System (Mini-PASS). We assessed the impact of the Mini-PASS handwashing station on handwashing, other water-related uses, and problems encountered over time.

METHODS

In this pre-postintervention study, we conducted semi-structured interviews by telephone seasonally with representatives of 71 households with the Mini-PASS from February 2021 through November 2022 to assess the impact of the units on water use and health.

RESULTS

Before Mini-PASS installation, all participating households primarily used washbasins for handwashing. Postintervention, more than 70% of households reported using the Mini-PASS as their primary handwashing method in all 3 follow-up intervals (3, 6-9, and 12 months postintervention). The proportion of households using the handwashing station for other household tasks increased during 12 months, from 51.4% (19 of 37) at 3 months postintervention to 77.8% (21 of 27) at 12 months postintervention. Although approximately 20% to 40% of households reported problems with their handwashing station during the 12 months postintervention, a large proportion of interviewees (47% to 60%) said they were able to conduct repairs themselves.

CONCLUSIONS

Households in rural Alaska quickly adopted the Mini-PASS for hand hygiene and other needs and were largely able to troubleshoot problems themselves. Further research evaluating the impact of improved handwashing behaviors facilitated by the Mini-PASS should be conducted.

Combating Fraudulent Participation in Urban American Indian and Alaska Native Virtual Health Research: Protocol for Increasing Data Integrity in Online Research (PRIOR)

BACKGROUND

While the advantages of using the internet and social media for research recruitment are well documented, the evolving online environment also enhances motivations for misrepresentation to receive incentives or to "troll" research studies. Such fraudulent assaults can compromise data integrity, with substantial losses in project time; money; and especially for vulnerable populations, research trust. With the rapid advent of new technology and ever-evolving social media platforms, it has become easier for misrepresentation to occur within online data collection. This perpetuation can occur by bots or individuals with malintent, but careful planning can help aid in filtering out fraudulent data.

OBJECTIVE

Using an example with urban American Indian and Alaska Native young women, this paper aims to describe PRIOR (Protocol for Increasing Data Integrity in Online Research), which is a 2-step integration protocol for combating fraudulent participation in online survey research.

METHODS

From February 2019 to August 2020, we recruited participants for formative research preparatory to an online randomized control trial of a preconceptual health program. First, we described our initial protocol for preventing fraudulent participation, which proved to be unsuccessful. Then, we described modifications we made in May 2020 to improve the protocol performance and the creation of PRIOR. Changes included transferring data collection platforms, collecting embedded geospatial variables, enabling timing features within the screening survey, creating URL links for each method or platform of data collection, and manually confirming potentially eligible participants' identifying information.

RESULTS

Before the implementation of PRIOR, the project experienced substantial fraudulent attempts at study enrollment, with less than 1% (n=6) of 1300 screened participants being identified as truly eligible. With the modified protocol, of the 461 individuals who completed a screening survey, 381 did not meet the eligibility criteria assessed on the survey. Of the 80 that did, 25 (31%) were identified as ineligible via PRIOR. A total of 55 (69%) were identified as eligible and verified in the protocol and were enrolled in the formative study.

CONCLUSIONS

Fraudulent surveys compromise study integrity, validity of the data, and trust among participant populations. They also deplete scarce research resources including respondent compensation and personnel time. Our approach of PRIOR to prevent online misrepresentation in data was successful. This paper reviews key elements regarding fraudulent data participation in online research and demonstrates why enhanced protocols to prevent fraudulent data collection are crucial for building trust with vulnerable populations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04376346; https://www.clinicaltrials.gov/study/NCT04376346.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52281.

Fatal Firearm Violence Among American Indians and Alaska Natives

There is a dearth of population-based studies regarding firearm-related deaths and years of potential life lost among American Indians and Alaska Natives (AI/AN). Using the Centers for Disease Control and Prevention's (CDC) We Based Injury Statistics Query and Reporting System (WISQARS) data for the three most recent years (2018-2020), we analyzed the demographic characteristics of AI/ANs who succumbed to firearm violence. AI/ANs averaged almost 500 firearm-related deaths per year. The majority of these deaths were observed among individuals 20-39 years of age (53%), males (84.4%), and in the West (55.3%). A plurality of these firearm-related deaths were suicides (48.9%) followed by homicides (43.5%). During the 3-year study period, the age-adjusted firearm death rate increased almost 5 times the growth of the AI/AN population. Also, a staggering 67,050 years of potential life were lost before the age of 80 years (YPLL80) during this period. Firearm suicides were responsible for the largest proportion of YPLL80s (48.5%). Traditional legal interventions [e.g., child access prevention (CAP) laws and extreme risk protection orders (ERPO)], if expanded to more states could potentially help reduce AI/AN firearm mortality. None of the 10 states with the highest firearm mortality of AI/AN have ERPOs and 8 of the 10 do not have CAP laws. Also, a renewed focus on cultural continuity and indigenous protective factors is essential to ameliorate the level of firearm violence in AI/ANs.

Medicolegal death investigations on tribal lands-underrepresented or underserved?

Death investigation on tribal lands and of American Indian/Alaska Native (AIAN) people is complex and not well documented. An analysis of data from the 2018 Census of Medical Examiner and Coroner Offices (CMEC) provides a timely update on the extent of medicolegal death investigations (MDIs) on federal and state-recognized tribal lands. An estimated 150 MEC offices serve tribal lands, however, 44 % of these offices (i.e., 4 % of MEC offices) do not track cases from tribal lands separately. MEC offices with a population of 25,000 to 250,000 that serve tribal lands had more resources and access to information to perform MDIs than all other MEC offices. Analysis also indicates that the median number of unidentified human remains cases from MECs serving tribal lands is 6 times higher than that of jurisdictions not serving tribal lands. This analysis begins to elucidate gaps in the nation's understanding of MDI on tribal lands.

Enablers and barriers to primary health care access for Indigenous adolescents: a systematic review and meta-aggregation of studies across Australia, Canada, New Zealand, and USA

BACKGROUND

Indigenous adolescents access primary health care services at lower rates, despite their greater health needs and experience of disadvantage. This systematic review identifies the enablers and barriers to primary health care access for Indigenous adolescents to inform service and policy improvements.

METHODS

We systematically searched databases for publications reporting enablers or barriers to primary health care access for Indigenous adolescents from the perspective of adolescents, their parents and health care providers, and included studies focused on Indigenous adolescents aged 10-24 years from Australia, Canada, New Zealand, and United States of America. Results were analyzed against the WHO Global standards for quality health-care services for adolescents. An additional ninth standard was added which focused on cultural safety.

RESULTS

A total of 41 studies were included. More barriers were identified than enablers, and against the WHO Global standards most enablers and barriers related to supply factors - providers' competencies, appropriate package of services, and cultural safety. Providers who built trust, respect, and relationships; appropriate package of service; and culturally safe environments and care were enablers to care reported by adolescents, and health care providers and parents. Embarrassment, shame, or fear; a lack of culturally appropriate services; and privacy and confidentiality were common barriers identified by both adolescent and health care providers and parents. Cultural safety was identified as a key issue among Indigenous adolescents. Enablers and barriers related to cultural safety included culturally appropriate services, culturally safe environment and care, traditional and cultural practices, cultural protocols, Indigenous health care providers, cultural training for health care providers, and colonization, intergenerational trauma, and racism. Nine recommendations were identified which aim to address the enablers and barriers associated with primary health care access for Indigenous adolescents.

CONCLUSION

This review provides important evidence to inform how services, organizations and governments can create accessible primary health care services that specifically meet the needs of Indigenous adolescents. We identify nine recommendations for improving the accessibility of primary health care services for Indigenous adolescents.

Rural Native Veterans' Perceptions of Care in the Context of Navigator Program Development

INTRODUCTION

American Indian and Alaska Natives serve in the military at one of the highest rates of all racial and ethnic groups. For Veterans, the already significant healthcare disparities Natives experience are aggravated by barriers to accessing care, care navigation, and coordination of health care within the Veterans Health Administration (VHA) between the VHA and tribal health systems. To mitigate these barriers, the VHA is developing a patient navigation program designed specifically for rural Native Veterans. We describe formative work aimed at understanding and addressing barriers to VHA care from the perspective of rural Native Veterans and those who facilitate their care.

METHODS

Thirty-four individuals participated in semi-structured interviews (22 Veterans, 6 family members, and 6 Veteran advocates) drawn from 9 tribal communities across the US.

RESULTS

Participants described many barriers to using the VHA, including perceptions of care scarcity, long travel distances to the VHA, high travel costs, and bureaucratic barriers including poor customer service, scheduling issues, and long waits for appointments. Many Veterans preferred IHS/tribal health care over the VHA due to its proximity, simplicity, ease of use, and quality.

CONCLUSION

Rural Native Veterans must see a clear benefit to using the VHA given the many obstacles to its use. Veteran recommendations for addressing barriers to VHA care within a navigation program include assistance enrolling in, scheduling, and navigating VHA systems; paperwork assistance; cost reimbursement; and care coordination with the IHS/tribal health care.

Physician Workforce Diversity Is Still Necessary and Achievable if It Is Intentionally Prioritized

The 2023 Supreme Court Decision from Students for Fair Admissions v. Harvard and Students for Fair Admissions v. University of North Carolina threatens the current progress in achieving diversity within undergraduate and graduate medical education. This is necessary to achieve a diverse healthcare workforce, which is a key to healing historical healthcare trauma, eliminating health disparities, and providing equitable healthcare access for all communities. Although the Supreme Court decision seems obstructionist, viable opportunities exist to enhance recruitment further and solidify diversity efforts in undergraduate and graduate medical education to achieve these goals.

Examining Characteristics of Local Public Health Systems With Exceptional Tribal Organization Participation

OBJECTIVE

To learn feasible ways to increase multisector community partnership with tribal organizations, meaning tribal health authorities or American Indian and Alaska Native (AI/AN)-serving organizations, by examining characteristics of local public health systems with exceptional tribal organization participation.

DESIGN, SETTING, AND PARTICIPANTS

In total, 728 local public health departments were surveyed in 2018 to generate a nationally representative sample of local public health systems in the United States. A positive deviance approach using logistic regression helped identify local public health systems that had tribal organization participation despite characteristics that make such participation statistically unlikely. Local public health systems with exceptional tribal organization participation were compared with systems with conventional participation, examining measures known to impact the formation of public health partnerships.

MAIN OUTCOME MEASURE

This study used an exploratory logistic regression approach to identify unique characteristics of local public health systems with exceptional tribal organization participation.

RESULTS

Of 728 health systems surveyed, 21 were identified as having exceptional tribal organization participation. Across varying thresholds to identify exceptional participation, having a higher network density and prioritizing equity in public health activities were found to consistently distinguish exceptional tribal organization participation in both nonrural and rural areas.

CONCLUSIONS

Public health partnerships with tribal organizations are possible even in circumstances that make them unlikely. Efforts to build denser networks of collaborating organizations and prioritize equity may help public health systems achieve success with tribal organization partnerships.

How Education Shapes Indigenous Health Inequalities in the USA and Mexico

Indigenous peoples around the world face significant health disparities relative to the dominant groups in their countries, yet the magnitude and patterns of health disparities vary across countries. We use data from the National Health Interview Survey and Mexican Family Life Survey to examine the health of Indigenous peoples in Mexico and American Indians and Alaska Natives in the USA and to evaluate how they fare relative to the majority populations in their countries (non-Indigenous Mexicans and non-Hispanic Whites, respectively). We assess disparities in self-rated health and activity limitations, with a focus on how Indigenous health disparities intersect with educational gradients in health. Regression analyses reveal three primary findings. First, Indigenous health disparities are larger in the USA than in Mexico. Second, differences in educational attainment account for most of the differences between Indigenous and non-Indigenous populations in Mexico, but less than half in the USA. Third, in both countries, health is moderated by educational attainment such that between-group disparities are largest at the highest levels of education. However, for Indigenous Mexicans there is a "cross-over" in which Indigenous Mexicans report better health at the lowest level of education. Overall, this study finds a weak relationship between education and Indigenous health, and raises the question about the validity of using traditional measures of SES in Indigenous contexts.

Disparities in preconception health indicators in U.S. women: a cross-sectional analysis of the behavioral risk factor surveillance system 2019

OBJECTIVES

Optimized preconception care improves birth outcomes and women's health. Yet, little research exists identifying inequities impacting preconception health. This study identifies age, race/ethnicity, education, urbanicity, and income inequities in preconception health.

METHODS

We performed a cross-sectional analysis of the Center for Disease Control and Prevention's (CDC) 2019 Behavioral Risk Factor Surveillance System (BRFSS). This study included women aged 18-49 years who (1) reported they were not using any type of contraceptive measure during their last sexual encounter (usage of condoms, birth control, etc.) and (2) reported wanting to become pregnant from the BRFSS Family Planning module. Sociodemographic variables included age, race/ethnicity, education, urbanicity, and annual household income. Preconception health indicators were subdivided into three categories of Physical/Mental Health, Healthcare Access, and Behavioral Health. Chi-squared statistical analysis was utilized to identify sociodemographic inequities in preconception health indicators.

RESULTS

Within the Physical/Mental Health category, we found statistically significant differences among depressive disorder, obesity, high blood pressure, and diabetes. In the Healthcare Access category, we found statistically significant differences in health insurance status, having a primary care doctor, and being able to afford a medical visit. Within the Behavioral Health category, we found statistically significant differences in smoking tobacco, consuming alcohol, exercising in the past 30 days, and fruit and vegetable consumption.

CONCLUSIONS

Maternal mortality and poor maternal health outcomes are influenced by many factors. Further research efforts to identify contributing factors will improve the implementation of targeted preventative measures in directly affected populations to alleviate the current maternal health crisis.

A, Clare C. B, Corey J. H, Hari E. The association between rurality, dual Medicare/Medicaid eligibility and chronic conditions with telehealth utilization: An analysis of 2019-2020 national Medicare claims

INTRODUCTION

Telehealth services have the potential to increase healthcare access among underserved populations, such as rural residents and racial/ethnic minority groups. The COVID-19 public health emergency led to unprecedented growth in telehealth utilization, but evidence suggests the growth has not been equitable across all patient populations. This study aimed to explore whether telehealth utilization and expansion changed equitably from 2019 to 2020 among sub-groups of Medicare beneficiaries.

METHODS

We conducted an analysis of telehealth utilization among a 20% random sample of 2019-2020 Medicare beneficiaries on a national level. We fit multivariable logistic regression models and calculated average marginal effects (AME) to assess the association between demographic and clinical characteristics on telehealth utilization.

RESULTS

We found telehealth utilization was less likely among non-Hispanic Black/African-American (2019: adjusted odds ratio [aOR] = 0.77, AME = -0.15; 2020: aOR = 0.85, AME = -3.50) and Hispanic (2019: aOR = 0.79, AME = -0.13; 2020: aOR = 0.87, AME = -2.89) beneficiaries, relative to non-Hispanic White beneficiaries in both 2019 and 2020, with larger disparities in 2020. Rural beneficiaries were more likely to utilize telehealth than urban beneficiaries in 2019 (aOR = 2.62, AME = 0.84), but less likely in 2020 (aOR = 0.57, AME = -14.47). In both years, dually eligible Medicare/Medicaid beneficiaries were more likely than non-dually eligible beneficiaries to utilize telehealth (2019: aOR = 4.75, AME = 0.84; 2020: aOR = 1.34, AME = 2.25). However, the effects of dual eligibility and rurality changed in both models as the number of chronic conditions increased.

DISCUSSION

We found evidence of increasing disparities in telehealth utilization among several Medicare beneficiary sub-groups in 2020 relative to 2019, including individuals of minority race/ethnicity, rural residents, and dually eligible beneficiaries, with disparities increasing among individuals with more chronic conditions. Although telehealth has the potential to address health inequities, our findings suggest that many of the patients in greatest need of healthcare are least likely to utilize telehealth services.

Deployment of Point-of-Care Echocardiography to Improve Cardiac Diagnostic Access Among American Indians

BACKGROUND

American Indians face significant barriers to diagnosis and management of cardiovascular disease. We sought to develop a real-world implementation model for improving access to echocardiography within the Indian Health Service, the American Indian Structural Heart Disease Partnership.

METHODS AND RESULTS

The American Indian Structural Heart Disease Partnership was implemented and evaluated via a 4-step process of characterizing the system where it would be instituted, building point-of-care echocardiography capacity, deploying active case finding for structural heart disease, and evaluating the approach from the perspective of the clinician and patient. Data were collected and analyzed using a parallel convergent mixed methods approach. Twelve health care providers successfully completed training in point-of-care echocardiography. While there was perceived usefulness of echocardiography, providers found it difficult to integrate screening point-of-care echocardiography into their workday given competing demands. By the end of 12 months, 6 providers continued to actively utilize point-of-care echocardiography. Patients who participated in the study felt it was an acceptable and effective approach. They also identified access to transportation as a notable challenge to accessing echocardiograms. Over the 12-month period, a total of 639 patients were screened, of which 36 (5.6%) had a new clinically significant abnormal finding.

CONCLUSIONS

The American Indian Structural Heart Disease Partnership model exhibited several promising strategies to improve access to screening echocardiography for American Indian populations. However, competing priorities for Indian Health Service providers' time limited the amount of integration of screening echocardiography into outpatient practice. Future endeavors should explore community-based solutions to develop a more sustainable model with greater impact on case detection, disease management, and improved outcomes.

Otolaryngology Care Disparities in American Indian Populations

Our objectives were to quantify geographical disparities in otolaryngology care access with respect to American Indian (AI) populations and to identify gaps in care. Although increased incidence and mortality rates of ear, nose, and throat (ENT) conditions in AI populations are well documented, few studies address factors contributing to these differential outcomes. We conducted a cross-sectional study of US states with AI areas that either met the population threshold for the American Community Survey annual estimate or annual supplemental estimate. A 2-tailed t test was used to compare the geographic distribution of ENT providers practicing within AI areas against non-AI areas, showing a statistically significant difference (P < .001) in the concentration of providers (0.409 vs 2.233 providers per 100,000 patients). To our knowledge, this is the first study to explore geographic barriers contributing to AI disparities within otolaryngology.

Race and ethnicity in the COVID-19 Critical Care Consortium: demographics, treatments, and outcomes, an international observational registry study

BACKGROUND

Improving access to healthcare for ethnic minorities is a public health priority in many countries, yet little is known about how to incorporate information on race, ethnicity, and related social determinants of health into large international studies. Most studies of differences in treatments and outcomes of COVID-19 associated with race and ethnicity are from single cities or countries.

METHODS

We present the breadth of race and ethnicity reported for patients in the COVID-19 Critical Care Consortium, an international observational cohort study from 380 sites across 32 countries. Patients from the United States, Australia, and South Africa were the focus of an analysis of treatments and in-hospital mortality stratified by race and ethnicity. Inclusion criteria were admission to intensive care for acute COVID-19 between January 14th, 2020, and February 15, 2022. Measurements included demographics, comorbidities, disease severity scores, treatments for organ failure, and in-hospital mortality.

RESULTS

Seven thousand three hundred ninety-four adults met the inclusion criteria. There was a wide variety of race and ethnicity designations. In the US, American Indian or Alaska Natives frequently received dialysis and mechanical ventilation and had the highest mortality. In Australia, organ failure scores were highest for Aboriginal/First Nations persons. The South Africa cohort ethnicities were predominantly Black African (50%) and Coloured* (28%). All patients in the South Africa cohort required mechanical ventilation. Mortality was highest for South Africa (68%), lowest for Australia (15%), and 30% in the US.

CONCLUSIONS

Disease severity was higher for Indigenous ethnicity groups in the US and Australia than for other ethnicities. Race and ethnicity groups with longstanding healthcare disparities were found to have high acuity from COVID-19 and high mortality. Because there is no global system of race and ethnicity classification, researchers designing case report forms for international studies should consider including related information, such as socioeconomic status or migration background. *Note: "Coloured" is an official, contemporary government census category of South Africa and is a term of self-identification of race and ethnicity of many citizens of South Africa.

Resilience and health in American Indians and Alaska Natives: A scoping review of the literature

American Indians and Alaska Natives suffer from disproportionately high rates of chronic mental and physical health conditions. These health inequities are linked to colonization and its downstream consequences. Most of the American Indian and Alaska Native health inequities research uses a deficit framework, failing to acknowledge the resilience of American Indian and Alaska Native people despite challenging historical and current contexts. This scoping review is based on a conceptual model which acknowledges the context of colonization and its consequences (psychological and health risk factors). However, rather than focusing on health risk, we focus on protective factors across three identified domains (social, psychological, and cultural/spiritual), and summarize documented relationships between these resilience factors and health outcomes. Based on the scoping review of the literature, we note gaps in extant knowledge and recommend future directions. The findings summarized here can be used to inform and shape future interventions which aim to optimize health and well-being in American Indian and Alaska Native peoples.

American Indian and Alaska Native substance use treatment: Barriers and facilitators according to an implementation framework

INTRODUCTION

Substance use disorder (SUD) and overdose deaths are higher in the American Indian and Alaska Native (AIAN) population than in other racial/ethnic groups. Multi-level gaps hinder SUD treatment for AIAN patients. Few studies have engaged front-line clinicians and administrators of SUD treatment programs serving AIAN patients to identify barriers and facilitators to improve the implementation of effective treatment.

METHODS

We conducted key informant interviews with a diverse sample of providers and administrators of SUD treatment programs across California regarding barriers and facilitators to treatment for AIAN patients. An AIAN-majority community advisory board (CAB) guided the development of an interview guide and helped to recruit respondents from five types of SUD programs statewide. Using ATLAS.ti, the research team coded interviews and classified emergent themes as barriers and facilitators related to Outer, Inner, and Individual domains of the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Representatives of 13 of 15 invited SUD treatment programs participated and 9 of the 13 interviewed self-identified as AIAN. Related to Outer Setting barriers from coded interviews, a dominant barrier was policies that defund or underfund SUD treatment, especially detoxification centers. Outer Setting facilitators included consistent Indian Health Service (IHS) eligibility criteria, judicial system connections for direct treatment access, and community programs advocating SUD treatment. Key themes related to barriers for the Inner Setting were limited bed capacity, poor coordination of intake and care, and lack of telehealth technology. Facilitators integrated mental health, linkage to external resources, and culturally centered care. Individual-level barriers were negative attitudes such as SUD stigma, distrust of governmental programs, and lack of transportation while individual engagement was facilitated by programs addressing negative attitudes and providing telemedicine for remote care.

CONCLUSION

The public health threat of SUD for the AIAN population mandates the implementation of interventions and policies that facilitate care. This qualitative study with primarily AIAN clinical leaders of SUD treatment highlights opportunities to improve care at multiple CFIR levels, focusing on capacity, coordination, culturally congruent care, and community initiatives to promote engagement.

Provider- and System-Level Barriers and Facilitators to Colonoscopy and Multi-Target Stool DNA for Colorectal Cancer Screening in Rural/Remote Alaska Native Communities

The Alaska Tribal Health System is working to increase colorectal cancer (CRC) screening among Alaska Native people, who experience the highest CRC rates in the world. This study examined CRC screening provider- and system-level barriers and facilitators from the perspective of healthcare providers serving Alaska Native people in rural/remote communities. A total of 28 provider (physicians, advanced practice, and Community Health Aides/Practitioners) interviews were held from 1 February to 30 November 2021. Colonoscopy provider-level barrier themes included time, competing priorities, and staffing, while system-level barriers included travel costs, weather, and the COVID-19 pandemic. Multi-target stool DNA (mt-sDNA) barrier themes included test viability and unfamiliarity, and previous stool tests experiences. For both tests, limited medical record reminders was a major barrier. Facilitator themes for both tests included community outreach, cultural competency and patient navigation, and clinic/system improvements. In-depth interviews with tribal health providers showed that adding mt-sDNA testing may help address system-level colonoscopy barriers such as waitlists and travel costs, but other barriers remain. Further research is needed into patient barriers and facilitators, as well as the effectiveness of integrating mt-sDNA into a geographically dispersed tribal health system to reduce cancer disparities and build equity in CRC prevention among Alaska Native people.

Change in testing for blood glucose during the COVID-19 pandemic, United States 2019-2021

AIM

This study assessed changes in testing for blood glucose in the United States (US) from 2019 to 2021.

METHODS

We conducted a serial cross-sectional analysis of the 2019-2021 National Health Interview Survey by including adults aged ≥ 18 years without reported diagnosed diabetes. We estimated the prevalence of testing for blood glucose within 12 months and the difference in the testing prevalence between 2019 and 2021.

RESULTS

The study sample included 82,594 respondents without diabetes in 2019--2021, with a mean age between 46.4 and 46.8 years. Overall, the prevalence of testing for blood glucose decreased significantly from 64.2 % (95 % confidence interval [CI] 63.3 %, 65.1 %) in 2019 to 60.0 % (95 % CI 59.1 %, 60.9 %) in 2021. Among adults who met the United States Preventive Services Task Force's 2015 screening recommendation, the prevalence decreased from 73.4 % (95 % CI 72.2 %, 74.6 %) to 69.5 % (95 % CI 68.3 %, 70.6 %). Although decreases in testing were observed in most groups, the extent of the decline differed by subgroups.

CONCLUSIONS

Testing for blood glucose decreased in the US during the COVID-19 pandemic. This may have delayed diagnosis and treatment of prediabetes and diabetes, underscoring the importance of continued access to diabetes screening during pandemics.

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.

Association of Reproductive Autonomy and Rates of State-Level Racialized Disparities in Preterm Birth and Low Birthweight

Introduction

Reproductive policies' impact on disparities in neonatal outcomes is understudied. Thus, we aimed to assess whether an index of reproductive autonomy is associated with black-white disparities in preterm birth (PTB) and low birthweight (LBW).

Methods

We used publicly available state-level PTB and LBW data for all live-births among persons aged 15-44 from January 1, 2016, to December 31, 2018. The independent measure was an index of state laws characterizing each state's reproductive autonomy, ranging from 5 (most restrictive) to 43 (most enabling), used continuously and as quartiles. Linear regression was performed to evaluate the association between both the index score (continuous, primary analysis; quartiles, secondary analysis) and state-level aggregated black-white disparity rates in PTB and LBW per 100 live births.

Results

Among 10,297,437 black (n=1,829,051 [17.8%]) and white (n=8,468,386 [82.2%]) births, rates of PTB and LBW were 6.46 and 8.24 per 100, respectively. Regression models found that every 1-U increase in the index was associated with a -0.06 (confidence interval [CI]: -0.10 to -0.01) and -0.05 (CI: -0.08, to -0.01) per 100 lower black-white disparity in PTB and LBW rates (p<0.05, p<0.01), respectively. The most enabling quartiles were associated with -1.21 (CI: -2.38 to -0.05) and -1.62 (CI: -2.89 to -0.35) per 100 lower rates of the black-white disparity in LBW, compared with the most restrictive quartile (both p<0.05).

Conclusion

Greater reproductive autonomy is associated with lower rates of state-level disparities in PTB and LBW. More research is needed to better understand the importance of state laws in shaping racialized disparities, reproductive autonomy, and birth outcomes.

Cardiovascular Disease Burden and Outcomes Among American Indian and Alaska Native Medicare Beneficiaries

Importance

American Indian and Alaska Native persons face significant health disparities; however, data regarding the burden of cardiovascular disease in the current era is limited.

Objective

To determine the incidence and prevalence of cardiovascular disease, the burden of comorbid conditions, including cardiovascular disease risk factors, and associated mortality among American Indian and Alaska Native patients with Medicare insurance.

Design, Setting, and Participants

This was a population-based cohort study conducted from January 2015 to December 2019 using Medicare administrative data. Participants included American Indian and Alaska Native Medicare beneficiaries 65 years and older enrolled in both Medicare part A and B fee-for-service Medicare. Statistical analyses were performed from November 2022 to April 2023.

Main Outcomes and Measures

The annual incidence, prevalence, and mortality associated with coronary artery disease (CAD), heart failure (HF), atrial fibrillation/flutter (AF), and cerebrovascular disease (stroke or transient ischemic attack [TIA]).

Results

Among 220 598 American Indian and Alaska Native Medicare beneficiaries, the median (IQR) age was 72.5 (68.5-79.0) years, 127 402 were female (57.8%), 78 438 (38.8%) came from communities in the most economically distressed quintile in the Distressed Communities Index. In the cohort, 44.8% of patients (98 833) were diagnosed with diabetes, 61.3% (135 124) were diagnosed with hyperlipidemia, and 72.2% (159 365) were diagnosed with hypertension during the study period. The prevalence of CAD was 38.6% (61 125 patients) in 2015 and 36.7% (68 130 patients) in 2019 (P < .001). The incidence of acute myocardial infarction increased from 6.9 per 1000 person-years in 2015 to 7.7 per 1000 patient-years in 2019 (percentage change, 4.79%; P < .001). The prevalence of HF was 22.9% (36 288 patients) in 2015 and 21.4% (39 857 patients) in 2019 (P < .001). The incidence of HF increased from 26.1 per 1000 person-years in 2015 to 27.0 per 1000 person-years in 2019 (percentage change, 4.08%; P < .001). AF had a stable prevalence of 9% during the study period (2015: 9.4% [14 899 patients] vs 2019: 9.3% [25 175 patients]). The incidence of stroke or TIA decreased slightly throughout the study period (12.7 per 1000 person-years in 2015 and 12.1 per 1000 person-years in 2019; percentage change, 5.08; P = .004). Fifty percent of patients (110 244) had at least 1 severe cardiovascular condition (CAD, HF, AF, or cerebrovascular disease), and the overall mortality rate for the cohort was 19.8% (43 589 patients).

Conclusions and Relevance

In this large cohort study of American Indian and Alaska Native patients with Medicare insurance in the US, results suggest a significant burden of cardiovascular disease and cardiometabolic risk factors. These results highlight the critical need for future efforts to prioritize the cardiovascular health of this population.

Behavioral health services in Urban American Indian Health Programs: Results from six site visits

This study explores behavioral health services for American Indians and Alaska Natives (AIANs) at six Urban Indian Health Programs (UIHPs). Interviews and focus groups with clinicians and staff inquired about behavioral health treatment available, service needs, client population, and financial and staffing challenges. Resulting site profiles were created based on focused coding and integrative memoing of site visit field notes and respondent transcripts. These six UIHPs evidenced diversity across multiple facets of service delivery even as they were united in their missions to provide accessible and effective behavioral health treatment to urban AIAN clients. Primary challenges to service provision included heterogenous client populations, low insurance coverage, limited provider knowledge, lack of resources, and incorporation of traditional healing. Collaborative research with UIHPs harbors the potential to recognize challenges, identify solutions, and share best practices across this crucial network of health care sites for improving urban AIAN well-being.

Disproportionate impact of COVID-19 severity and mortality on hospitalized American Indian/Alaska Native patients

Epidemiological data across the United States of America illustrate health disparities in COVID-19 infection, hospitalization, and mortality by race/ethnicity. However, limited information is available from prospective observational studies in hospitalized patients, particularly for American Indian or Alaska Native (AI/AN) populations. Here, we present risk factors associated with severe COVID-19 and mortality in patients (4/2020-12/2021, n = 475) at the University of New Mexico Hospital. Data were collected on patient demographics, infection duration, laboratory measures, comorbidities, treatment(s), major clinical events, and in-hospital mortality. Severe disease was defined by COVID-related intensive care unit requirements and/or death. The cohort was stratified by self-reported race/ethnicity: AI/AN (30.7%), Hispanic (47.0%), non-Hispanic White (NHW, 18.5%), and Other (4.0%, not included in statistical comparisons). Despite similar timing of infection and comparable comorbidities, admission characteristics for AI/AN patients included younger age (P = 0.02), higher invasive mechanical ventilation requirements (P = 0.0001), and laboratory values indicative of more severe disease. Throughout hospitalization, the AI/AN group also experienced elevated invasive mechanical ventilation (P < 0.0001), shock (P = 0.01), encephalopathy (P = 0.02), and severe COVID-19 (P = 0.0002), consistent with longer hospitalization (P < 0.0001). Self-reported AI/AN race/ethnicity emerged as the highest risk factor for severe COVID-19 (OR = 3.19; 95% CI = 1.70-6.01; P = 0.0003) and was a predictor of in-hospital mortality (OR = 2.35; 95% CI = 1.12-4.92; P = 0.02). Results from this study highlight the disproportionate impact of COVID-19 on hospitalized AI/AN patients, who experienced more severe illness and associated mortality, compared to Hispanic and NHW patients, even when accounting for symptom onset and comorbid conditions. These findings underscore the need for interventions and resources to address health disparities in the COVID-19 pandemic.

Because its power remains naturalized: introducing the settler colonial determinants of health

Indigenous people suffer earlier death and more frequent and severe disease than their settler counterparts, a remarkably persistent reality over time, across settler colonized geographies, and despite their ongoing resistance to elimination. Although these health inequities are well-known, they have been impervious to comprehensive and convincing explication, let alone remediation. Settler colonial studies, a fast-growing multidisciplinary and interdisciplinary field, is a promising candidate to rectify this impasse. Settler colonialism's relationship to health inequity is at once obvious and incompletely described, a paradox arising from epistemic coloniality and perceived analytic challenges that we address here in three parts. First, in considering settler colonialism an enduring structure rather than a past event, and by wedding this fundamental insight to the ascendant structural paradigm for understanding health inequities, a picture emerges in which this system of power serves as a foundational and ongoing configuration determining social and political mechanisms that impose on human health. Second, because modern racialization has served to solidify and maintain the hierarchies of colonial relations, settler colonialism adds explanatory power to racism's health impacts and potential amelioration by historicizing this process for differentially racialized groups. Finally, advances in structural racism methodologies and the work of a few visionary scholars have already begun to elucidate the possibilities for a body of literature linking settler colonialism and health, illuminating future research opportunities and pathways toward the decolonization required for health equity.

Racial and Ethnic Equity in Care for Hypertension and Diabetes in an Urban Indian Health Organization

Approximately 70% of American Indian/Alaska Native (AI/AN) individuals reside in urban areas. Urban Indian Health Organizations (UIHOs) provide culturally engaged primary care for AI/AN patients and members of other racial and ethnic groups who have experienced disparities in diabetes and hypertension care, and are commonly affected by social and economic barriers to care. We assessed whether disparities were present between the racial and ethnic groups served by the largest UIHO in the USA. We developed retrospective cohorts of patients with hypertension or diabetes receiving primary care from this UIHO, measuring differences between AI/AN, Spanish-preferring Latinx, English-preferring Latinx, Black, and White patients in mean systolic blood pressure (SBP) and mean hemoglobin A1c (A1c) as primary outcomes. To assess processes of care, we also compared visit intensity, missed visits, and medication treatment intensity in regression models adjusted for sociodemographic and clinical characteristics. For hypertension (n = 2148), adjusted mean SBP ranged from 135.8 mm Hg among Whites to 141.3 mm Hg among Blacks (p = 0.06). For diabetes (n = 1211), adjusted A1c ranged from 7.7% among English-preferring Latinx to 8.7% among Blacks (p = 0.38). Care processes for both hypertension and diabetes varied across groups. No group consistently received lower-quality care. This UIHO provided care of comparable quality for hypertension and diabetes among urban-dwelling AI/ANs and members of other racial, ethnic, and language preference groups. Systematic assessments of care quality in UIHOs may help demonstrate the importance of their role in providing care and improve the quality of care.

Incorporating resilience when assessing pandemic risk in the Arctic: a case study of Alaska

The discourse on vulnerability to COVID-19 or any other pandemic is about the susceptibility to the effects of disease outbreaks. Over time, vulnerability has been assessed through various indices calculated using a confluence of societal factors. However, categorising Arctic communities, without considering their socioeconomic, cultural and demographic uniqueness, into the high and low continuum of vulnerability using universal indicators will undoubtedly result in the underestimation of the communities' capacity to withstand and recover from pandemic exposure. By recognising vulnerability and resilience as two separate but interrelated dimensions, this study reviews the Arctic communities' ability to cope with pandemic risks. In particular, we have developed a pandemic vulnerability-resilience framework for Alaska to examine the potential community-level risks of COVID-19 or future pandemics. Based on the combined assessment of the vulnerability and resilience indices, we found that not all highly vulnerable census areas and boroughs had experienced COVID-19 epidemiological outcomes with similar severity. The more resilient a census area or borough is, the lower the cumulative death per 100 000 and case fatality ratio in that area. The insight that pandemic risks are the result of the interaction between vulnerability and resilience could help public officials and concerned parties to accurately identify the populations and communities at most risk or with the greatest need, which, in turn, helps in the efficient allocation of resources and services before, during and after a pandemic. A resilience-vulnerability-focused approach described in this paper can be applied to assess the potential effect of COVID-19 and similar future health crises in remote regions or regions with large Indigenous populations in other parts of the world.

"Make Stories That Will Always Be There": Eagle Books' Appeal, Sustainability, and Contributions to Public Health, 2006-2022

PURPOSE AND OBJECTIVES

We aimed to determine why the Eagle Books, an illustrated series for American Indian and Alaska Native (AIAN) children to address type 2 diabetes, remain viable long after their release. We sought to answer 2 questions: Why did the books maintain popularity? What factors have sustained them?

INTERVENTION APPROACH

Type 2 diabetes burgeoned in the US after World War II, compounding a long legacy of injustices for AIAN peoples. By the 1980s, their rates soared above those of White people. Concerned for future generations, Tribal Leaders suggested that the Centers for Disease Control and Prevention and Indian Health Service use traditional storytelling to teach children about staying healthy. Public health interventions are most effective when culture and history are integrated into health education, particularly stories to address a relatively new disease for AIAN peoples.

EVALUATION METHODS

From 2008 through 2013, we conducted a case study among 8 tribal communities to evaluate the uptake of the Eagle Books across Indian Country. To understand the Eagle Books' sustained appeal, in 2022 we reanalyzed the original case study themes and analyzed for the first time themes that emerged from evaluation results in the Eagle Books' program literature. These were programs that had independently evaluated their use of the Eagle Books and published their findings.

RESULTS

Outcomes demonstrated continuous application of the Eagle Books in diverse community interventions, influencing children's healthy choices. Community implementers described sustainability components, such as the books' versatility, flexibility of use, and availability online and in print.

IMPLICATIONS FOR PUBLIC HEALTH

Historical, social, economic, and environmental health determinants intersect with biological and behavioral factors to weave a complex web of causation for type 2 diabetes, beginning early in life. Compelling, colorful stories reflecting traditional wisdom and respect for Western and Indigenous science - through the eyes of a wise eagle, a clever rabbit, a tricky coyote, and kids in T-shirts and sneakers - can positively influence community health.

Culturally tailored substance use interventions for Indigenous people of North America: a systematic review

Purpose–

The purpose of the current study is to conduct a systematic review of peer-reviewed work on culturally tailored interventions for alcohol and drug use in Indigenous adults in North America. Substance use has been reported as a health concern for many Indigenous communities. Indigenous groups experienced the highest drug overdose death rates in 2015, the largest percentage increase in the number of deaths over time from 1999 to 2015 compared to any other racial group. However, few Indigenous individuals report participating in treatment for alcohol or drug use, which may reflect the limited engagement that Indigenous groups have with treatment options that are accessible, effective and culturally integrative.

Design/methodology/approach–

Electronic searches were conducted from 2000 to April 21, 2021, using PsycINFO, Cumulative Index to Nursing and Allied Health Literature, MEDLINE and PubMed. Two reviewers classified abstracts for study inclusion, resulting in 18 studies.

Findings–

Most studies were conducted in the USA (89%). Interventions were largely implemented in Tribal/rural settings (61%), with a minority implemented in both Tribal and urban contexts (11%). Study samples ranged from 4 to 742 clients. Interventions were most often conducted in residential treatment settings (39%). Only one (6%) intervention focused on opioid use among Indigenous people. Most interventions addressed the use of both drugs and alcohol (72%), with only three (17%) interventions specifically intended to reduce alcohol use.

Originality/value–

The results of this research lend insight into the characteristics of culturally integrative treatment options for Indigenous groups and highlight the need for increased investment in research related to culturally tailored treatment across the diverse landscape of Indigenous populations.

Neighborhood Deprivation, Hospital Quality, and Mortality After Cancer Surgery

OBJECTIVE

To evaluate if receipt of complex cancer surgery at high-quality hospitals is associated with a reduction in disparities between individuals living in the most and least deprived neighborhoods.

BACKGROUND

The association between social risk factors and worse surgical outcomes for patients undergoing high-risk cancer operations is well documented. To what extent neighborhood socioeconomic deprivation as an isolated social risk factor known to be associated with worse outcomes can be mitigated by hospital quality is less known.

METHODS

Using 100% Medicare fee-for-service claims, we analyzed data on 212,962 Medicare beneficiaries more than age 65 undergoing liver resection, rectal resection, lung resection, esophagectomy, and pancreaticoduodenectomy for cancer between 2014 and 2018. Clinical risk-adjusted 30-day postoperative mortality rates were used to stratify hospitals into quintiles of quality. Beneficiaries were stratified into quintiles based on census tract Area Deprivation Index. The association of hospital quality and neighborhood deprivation with 30-day mortality was assessed using logistic regression.

RESULTS

There were 212,962 patients in the cohort including 109,419 (51.4%) men with a mean (SD) age of 73.8 (5.9) years old. At low-quality hospitals, patients living in the most deprived areas had significantly higher risk-adjusted mortality than those from the least deprived areas for all procedures; esophagectomy: 22.3% versus 20.7%; P <0.003, liver resection 19.3% versus 16.4%; P <0.001, pancreatic resection 15.9% versus 12.9%; P <0.001, lung resection 8.3% versus 7.8%; P <0.001, rectal resection 8.8% versus 8.1%; P <0.001. Surgery at a high-quality hospitals was associated with no significant differences in mortality between individuals living in the most compared with least deprived neighborhoods for esophagectomy, rectal resection, liver resection, and pancreatectomy. For example, the adjusted odds of mortality between individuals living in the most deprived compared with least deprived neighborhoods following esophagectomy at low-quality hospitals (odds ratio=1.22, 95% CI: 1.14-1.31, P <0.001) was higher than at high-quality hospitals (odds ratio=0.98, 95% CI: 0.94-1.02, P =0.03).

CONCLUSION AND RELEVANCE

Receipt of complex cancer surgery at a high-quality hospital was associated with no significant differences in mortality between individuals living in the most deprived neighborhoods compared with least deprived. Initiatives to increase access referrals to high-quality hospitals for patients from high deprivation levels may improve outcomes and contribute to mitigating disparities.

Associations Between Rurality, pre-pregnancy Health Status, and Macrosomia in American Indian/Alaska Native Populations

OBJECTIVES

To examine the relationships between pre-pregnancy diabetes mellitus (DM), gestational diabetes mellitus (GDM), pre-pregnancy body mass index (BMI) and county-level social determinants of health, with infant macrosomia within a sample of American Indian/Alaska Native (AI/AN) women receiving Indian Health Service (IHS) care.

METHODS

The sample included women-infant dyads representing 1,136 singleton births from fiscal year 2011 (10/1/2019-9/30/2011). Data stemmed from the IHS Improving Health Care Delivery Data Project. Multivariate generalized linear mixed models were fitted to assess the association of macrosomia with pre-pregnancy health status and social determinants of health.

RESULTS

Nearly half of the women in the sample were under age 25 years (48.6%), and most had Medicaid health insurance coverage (76.7%). Of those with a pre-pregnancy BMI measure, 66.2% were overweight or obese. Although few women had pre-pregnancy DM (4.0%), GDM was present in 12.8% of women. Most women had a normal term delivery (85.4%). Overweight, obesity, pre-pregnancy DM, and county-level rurality were all significantly associated with higher odds of infant macrosomia.

Advancing Diabetes Prevention and Control in American Indians and Alaska Natives

As with many Indigenous populations globally, American Indians and Alaska Natives (AI/ANs) experience high rates of type 2 diabetes. Prevention efforts, ongoing medical care, patient self-management education, and support to prevent and reduce the risk of long-term complications must be developed to limit the impact of diabetes on individuals, families, and communities. Diabetes prevention and control require both individual- and community-level efforts as well as policies that attempt to mitigate contributing adverse socioeconomic factors. Congressional funding since 1998 continues to address the epidemic of diabetes in AI/AN groups with the Special Diabetes Program for Indians (SDPI), which has resulted in significant outcomes and key lessons that can inform new efforts to prevent diabetes in other populations and communities. The purpose of this review is to understand the context behind the epidemic of diabetes in AI/ANs, review the impact of the SDPI on prevention and control of diabetes as well as the translation of these strategies into clinical practice and their influence on health practice, and identify lessons learned for future efforts to address this ongoing challenge for AI/AN and other communities suffering from type 2 diabetes.