"We don't separate out these things. Everything is related": Partnerships with Indigenous Communities to Design, Implement, and Evaluate Multilevel Interventions to Reduce Health Disparities

Multilevel interventions (MLIs) are appropriate to reduce health disparities among Indigenous peoples because of their ability to address these communities' diverse histories, dynamics, cultures, politics, and environments. Intervention science has highlighted the importance of context-sensitive MLIs in Indigenous communities that can prioritize Indigenous and local knowledge systems and emphasize the collective versus the individual. This paradigm shift away from individual-level focus interventions to community-level focus interventions underscores the need for community engagement and diverse partnerships in MLI design, implementation, and evaluation. In this paper, we discuss three case studies addressing how Indigenous partners collaborated with researchers in each stage of the design, implementation, and evaluation of MLIs to reduce health disparities impacting their communities. We highlight the following: (1) collaborations with multiple, diverse tribal partners to carry out MLIs which require iterative, consistent conversations over time; (2) inclusion of qualitative and Indigenous research methods in MLIs as a way to honor Indigenous and local knowledge systems as well as a way to understand a health disparity phenomenon in a community; and (3) relationship building, maintenance, and mutual respect among MLI partners to reconcile past research abuses, prevent extractive research practices, decolonize research processes, and generate co-created knowledge between Indigenous and academic communities.

Baseline results from NenŨnkUmbi/EdaHiYedo: A randomized clinical trial to improve sexual and reproductive health among American Indian adolescents

We report on baseline findings from NenUnkUmbi/EdaHiYedo, a community based participatory research randomized controlled trial with American Indian adolescents to reduce sexual and reproductive health disparities. American Indian adolescents aged 13-19 years participated in a baseline survey that was administered in five schools. We used zero-inflated negative binomial regression to evaluate how the count of protected sexual acts was associated with independent variables of interest. We stratified models by self-reported gender of adolescents and tested for a two-way interaction effect between gender and the independent variable of interest. Two hundred twenty-three girls and 222 boys (n = 445) were sampled. The average number of lifetime partners was 1.0 (standard deviation = 1.7). Each additional lifetime partner was associated with a 50% increase in the number of protected sexual acts incident rate ratio (IRR = 1.5, 95% confidence interval [CI] 1.1-1.9) and more than a twofold increase in the likelihood of not having protected sexual acts (adjusted odd ratio [aOR] = 2.6, 95% CI 1.3-5.1). Each additional number of substances used in adolescentss' lifetime was associated with an increased likelihood of not having protected sexual acts (aOR = 1.2, 95% CI 1.0-1.5). In boys, each one standard deviation increase in depression severity was associated with a 50% reduction in the number of times a condom was used adjusted IRR (aIRR = 0.5, 95% CI 0.4-0.6, p < .001). Each 1-unit increase in positive prospections of pregnancy was associated with a pronounced decrease likelihood of not having protected sexual acts (aOR = 0.01, 95% CI 0.0-0.1). Findings support the importance of tribally driven tailoring of sexual and reproducive health interventions and services for American Indian adolescents.

Multiyear, Multisectoral Training Program in Kenya to Enhance Medical-Legal Processes in Response to Sexual and Gender-Based Violence

Sexual and gender-based violence (SGBV) leads to severe sequelae for individuals and communities. Lack of cross-sector coordination inhibits effective medical-legal support and justice for survivors. Multisectoral trainings for health, legal, and law enforcement professionals on survivor-centered SGBV care were conducted in Kenya during 2012-2018. Evaluation utilized objective structured clinical examinations, standardized patients, knowledge assessments, and interviews. A total of 446 professionals participated in 18 trainings. Mean knowledge scores increased from 75.6% to 84.7% (p < .001). Thirty interviews revealed improved survivor confidentiality, increased specialized hospital care, more comprehensive forensic care, and greater cross-sector collaboration. Participants reported survivors feeling more comfortable pursuing legal action and increased perpetrator convictions.

Characterization of Lifetime Agrichemical Exposure Sequences Relative to International Migration in Foreign Born Latinx Agricultural Workers Living in South Florida

There is a limited understanding of how toxic exposures to agrichemicals vary relative to international migration over the life course. A life history calendar (LHC) was piloted to explore sequences of agrichemical exposure relative to international migration. LHCs were administered to 41 foreign born individuals from Mexico and Central America who had agricultural work experience during their lifetime and who were living in South Florida. Social sequence analysis was used to explore occupation-by-agrichemical events relative to migration. A three-cluster solution was used to classify low, moderate, and high lifetime exposure sequences. The odds of any perceived effects of agrichemicals on the body increased with time prior to migration in the moderate and high exposure sequence clusters and continued to increase 20% with each year following migration in the moderate exposure cluster. Workers with high lifetime agrichemical exposures prior to migrating internationally showed lower likelihoods of a perceived effect on the body following migration despite continued exposure. Further research on instrument validity is warranted.

An ecological approach to understanding Women's reproductive health and pregnancy decision making in Greenland

Using a community based participatory research framework and ecological systems theory we explored the experiences of reproductive health among Inuit women living in a remote Northwestern settlement in Greenland to understand the multiple diverse factors that influence their pregnancy outcomes. We conducted 15 in depth interviews with Inuit women between the ages of 19 and 45. Key factors influencing women's pregnancy decision making were: 1) precursors to pregnancy; 2) birth control use; 3) adoption and abortion; and 4) access to reproductive health care. Our results highlight the need to identify pathways through research, policy, health promotion, and health care practice that can support Inuit women in Greenland to be reproductively healthy and make informed decisions about pregnancy that resonate with their cultural beliefs as well as the realities of their everyday lives. We recommend the integration of cultural messaging into interdisciplinary approaches for preventive reproductive health care with women living in remote Arctic communities.

A qualitative study of services accessibility for indigenous persons who use injection drugs across three communities in the United States

Aims: This study concerns the perspectives of Indigenous persons who use injection drugs (IPWIDs) and key stakeholders across multiple sectors regarding healthcare service and treatment accessibility in the United States.Methods: Sixty in-depth interviews were undertaken with selected participants (30 people who use injection drugs and 30 stakeholders) across three non-urban locations in the United States. An inductive analytic approach was used to explore perspectives regarding healthcare accessibility gaps.Results: IPWIDs described injecting stimulants, opioids, and diverted medications for opioid use disorder, as well as having unstable access to sterile syringes. Often, the most accessible treatment for IPWID substance use was engagement with punitive aspects of the criminal justice system. While local health and social services were described as providing limited or inadequate services for IPWIDs, human capital deficiencies in those agencies and institutions often reinforced barriers to accessibility for IPWIDs, further aggravating the epidemics of Hepatitis C Virus infection and overdose risk in Indigenous communities. Conclusions: Decolonizing approaches to IPWID-centered services are urgently needed to reduce disparities in transmission of infectious diseases and other health consequences of injection drug use among American Indian people. Potential pathways forward include moving away from punitive treatment of IPWIDs by the criminal justice system and toward local, tribally-centered, culturally appropriate treatment models. We identify an urgent need to provide reliable and local access to sterile injection equipment and opioid substitution treatment on or near reservations.

Narrative frames as choice over structure of American Indian sexual and reproductive health consequences of historical trauma

Emerging evidence suggests that the historical trauma associated with settler colonialism affects the sexual and reproductive health (SRH) of American Indian (AI) communities today. This article examines how one AI community narratively frames the influence of historical trauma within the context of community-based participatory research (CBPR) and the implications of this framing for health behaviours, internalized oppression, SRH outcomes, and future CBPR interventions. We found that AIs framed the SRH consequences of historical trauma with renderings that favoured personal choice over structural explanations. Our findings suggest future interventions could: (1) include educational components on historical trauma and the continued role settler colonialism plays in structural violence against AI bodies and communities; and (2) recognize the role that the individualized logic of westernized/white culture may play in the erasure of traditional collectivist AI culture, internalized oppression, and SRH.

Genitourinary Systems Entangled with Shifting Environments in a Salvadoran Subsistence Farming Community

Diseases of the genitourinary system are the leading cause of hospital deaths in El Salvador, and chronic kidney disease of unknown origin has been gaining attention as a public health problem among farmers in particular. Epidemiological studies point, in part, to environmental risk factors, which have shifted over time with the deployment of modern agricultural science and ongoing climate change. We examined how diseases of the genitourinary system were situated at several margins of an epidemic in one rural Salvadoran municipality where these environmental and epidemiological changes are occurring, albeit relatively slow. By using this approach to study diseases of the genitourinary system, we illustrate one way in which shifting human/environment entanglements can be experimentally "known" in the context of human diseases associated with them. Our approach offers a unique perspective in thinking with ethnographic data to compliment ongoing epidemiological investigations of kidney disease in El Salvador.

Sexual risk behaviors and the legacy of colonial violence among Northern plains American Indian youth: A mixed methods exploratory study

INTRODUCTION

In this article, we honor the tribal remembering of two Northern Plains tribes to illustrate how the legacy of colonial violence frames the way in which substance use and mental health affect sexual risk behaviors among American Indian youth on the reservation today.

METHODS

We used a multi-phase, mixed quantitative and qualitative methods design within a community based participatory research framework to illustrate how the legacy of colonial violence frames epidemiological links between substance use, mental health, and sexual risk behavior among American Indian youth. We conducted semistructured interviews with 29 individuals and administered questionnaires to 298 American Indian youth living in a reservation environment.

RESULTS

Our findings explicate how a legacy of colonial violence underlies epidemiological links between mental health and substance use with sexual risk behavior among youth. Salient facets of colonial violence included systematically altered living arrangements, the boarding school era, eroded traditional practices, and the entry of extractive industries onto native lands.

DISCUSSION

The colonial violence enacted against the ancestors of Northern Plains tribal peoples materializes in the health of those living on the reservation today. Community interventions, which seek to address the role of substance use and mental health in sexual risk behavior, could benefit from delineating tribal perceptions regarding the legacy of colonial violence on public health outcomes through the use of a CBPR framework.

Self-reported Exposure to Sexual and Reproductive Health Information among American Indian Youth: Implications for Technology Based Intervention

While technology-based interventions show promise in certain populations of American youth, the technology may intrinsically widen intergenerational communication chasms associated with youth's increased access to Smartphone technologies. The authors examined self-reported exposure to sexual and reproductive health information and evaluated its relationship with sexual risk behaviors with American Indian youth. Approximately 296 students, ages of 15-18 years old, were surveyed to examine self-reported exposure and attitudes to information received about sexual intercourse, reproduction, and social media use in relation to sexual risk behaviors. Results indicate that information received regarding sexual intercourse and birth control from intra-familial network members was associated with more engagement in sex, and that increased social media use to talk or learn about sex was associated with not using a condom at the last sexual encounter. We advise that researchers and programmers considering technology-based interventions with AI communities carefully consider the gravity of investing preventive resources into technology-based interventions that may further deepen communication gaps that youth experience within their community networks.

Attitudes Toward Sexual Violence Survivors: Differences Across Professional Sectors in Kenya and the Democratic Republic of the Congo

Sexual violence survivors who decide to report their assault interact with health care, law enforcement, and legal and judicial professionals. Professionals' attitudes about sexual violence and survivors play an important role in caring for survivors and in the pursuit of justice. Despite evidence showing the relationship between service provider beliefs and survivor outcomes, relatively little is known about professionals' beliefs about sexual violence or their attitudes toward sexual violence survivors. Between June 2012 and December 2014, our study examined the beliefs and attitudes of 181 professionals from the health care, legal, and law enforcement sectors in the Eastern Democratic Republic of the Congo (DRC) and the Rift Valley region of Kenya, areas with a high prevalence of sexual violence. To determine correlates of beliefs and attitudes about sexual violence and sexual violence survivors, multiple logistic regression models were adjusted for demographic and occupational characteristics. Respondents who agreed that survivors got what they deserved (7%) or that survivors should feel ashamed (9%) were the minority, while those who would be willing to care for a family member with a history of sexual violence (94%) were the majority. Profession was significantly associated with beliefs and attitudes about sexual violence and survivors. Law enforcement professionals were more likely than health professionals and lawyers to indicate that survivors should feel ashamed. Our findings suggest a need for interventions that adequately address potentially harmful beliefs and attitudes of some professionals serving sexual violence survivors.

A preliminary needs assessment of American Indians who inject drugs in northeastern Montana

Background

Injection drug use has not been well documented in American Indians living in the USA. American Indian and Alaskan Natives (AI/ANs) show higher rates of substance use compared to the general population, and have historically been subject to a number of risk factors that are known to increase the likelihood of substance use. AI/ANs also experience increased risk for infectious diseases that are transmitted via injection drug use and/or sexual activity. Harm reduction approaches have been shown to be effective for decreasing risk of disease transmission in at-risk populations, and may be well suited for AI/AN injection drug users residing in rural reservation communities. In this study, we aimed to examine the characteristics of American Indians (AI) who use injection drugs (PWUID) in northeastern Montana to identify needs that could be addressed with harm reduction programming.

Methods

For the present study, we used a respondent-driven sampling approach to generate a sample of 51 self-identified male and female injection drug users ≥18 years of age who were American Indians living on the Fort Peck Indian Reservation. Sampling weights were applied to all analyses using Respondent-Driven Sampling Analysis Tool (RDSAT).

Results

There were no strong recruitment patterns by age, sex, or ethnic identity status of the recruiter or participant, but there were strong within-group recruitment patterns by location within the reservation. The majority of the sample reported initiating substance use before the age of 18. Participants reported significant risk for HIV, hepatitis, and other infectious diseases through their drug use and/or risky sexual behavior. Sixty-five percent reported having reused syringes, and 53% reported drawing from the same filter. Seventy-five percent reported inconsistent condom use during the 3 months preceding the survey, and 53% reported injecting drugs during sex during the 3 months preceding the survey. Only 66% of participants reported having been tested for HIV in the 12 months preceding the survey. The vast majority (98%) of respondents expressed interest in a harm reduction program. Seventy-six percent reported that it was easy or very easy to obtain new syringes.

Conclusions

We documented several risks for blood-borne pathogens, including elevated levels of syringe reuse. Further, we documented significant interest in harm reduction interventions in the present sample of AI/AN injection drug users. Findings suggest a need for increased access to harm reduction programming for AI/AN injection drug users to reduce the transmission of infectious disease and increase access to compassionate care.

The effectiveness of an education intervention to prevent chlamydia infection among Greenlandic youth

The purpose of this study was to implement a sexual health behavioural intervention in Greenland in order to reduce sexually transmitted infection rates among a population of Greenland youth. This behavioural intervention was called Inuulluataarneq (Having the Good Life). Inuulluataarneq's objects included: (1) increase Greenlandic youth's overall knowledge about sexually transmitted infections and sexual health; (2) increase parent/guardian-youth communication about topics related to sexually transmitted infections and sex; and (3) increase consistent condom use among Greenlandic youth. We hypothesised that increased awareness of sexually transmitted infections and sexual health as well as increased communication between parents/guardians and their adolescent children would influence sexual risk behaviour and reduce sexually transmitted infections among our sample population, with a focus on urine samples of chlamydia infection. Results indicate that the influence of having a parent/guardian to speak with about topics related to sex, including the consequences of pregnancy, are key protective factors in reducing sexually transmitted infections among Greenlandic youth. Inuulluataarneq demonstrates that intensive short-term education and skill-building delivered by a trained community member is an effective sexually transmitted infection prevention intervention method among young Inuit populations who live in small isolated Arctic communities.

A trial of questionnaire administration modalities for measures of sexual risk behaviour in the uniformed services of Peru

Summary

Modalities of questionnaire administration may affect data quality, particularly when conducting Biological and Behavioral Surveillance Surveys (BBSS) of uniformed personnel. We aimed to examine differences in administration, reporting and data quality across several common modalities of administration for BBSS endeavors. Prior to a large-scale BBSS endeavor with the uniformed services of Peru, we pilot tested three modes of questionnaire administration among personnel engaged in internal combat: face-to-face interview (FFI), self-administered paper-based interview (SAPI), and audio computer-assisted self-interview (ACASI). Individuals who took the survey using ACASI were less likely to have missing data on measures of sexual risk and alcohol abuse and were more likely to report sexual risk behaviours and symptoms of alcohol abuse; however, more individuals took the survey using SAPI given inadequate time to devote to sitting through an entire FFI or ACASI. Sexually transmitted infections did not vary significantly across modes of questionnaire administration. While more logistically complicated for BBSS efforts in resource-constrained settings, we recommend the use of ACASI in collecting BBSS data from uniformed personnel if conditions are permissible.

Abstract P4-13-02: Comparing data quality of client intake forms by interview mode: results of a pilot study on the use of audio computer-assisted self-interview (ACASI) in the Avon Breast Health Outreach Program

Background: Numerous studies have documented the relative advantages that computer assisted self-interview (CASI) technology holds over traditional interviewing methods in collecting research data on stigmatized and/or risky health behaviors. However, few studies have explored the broader implications of using CASI to collect basic client-level data during routine health promotion and disease prevention screenings.

Aims: The present study aims to address this gap in research by comparing the quality of client-level data collected via audio-computer assisted self-interview (ACASI) with data collected via face-to-face and self-administered paper-based interviews among a sample of clients served through the Avon Breast Health Outreach Program (Avon BHOP).

Methods: A total of 303 clients served through the Avon BHOP were sampled from three U.S. sites between November 2011 and March 2012. Clients were randomly assigned to complete the Avon BHOP client intake form (CIF) via one of three interview modes: face-to-face interview (FFI), self-administered paper-based interview (SAPI), or ACASI. We conducted logistic regression and determined odds ratios with 95% confidence intervals to test our hypothesis that use of ACASI would result in significantly higher rates of CIF completion than either FFI or SAPI. We compared rates of completion of the entire CIF, as well as completion of each of the three CIF sections: Demographics, Breast Health Information, and Correlates of Breast Health.

Results: Clients were significantly more likely to complete the entire CIF via ACASI than either FFI or SAPI interview modes. The greatest differences were observed when comparing rates of completion between ACASI and SAPI, as clients were almost five times more likely to complete the CIF via ACASI as opposed to SAPI (OR = 4.7, p &lt; 0.001). Additionally, when comparing rates of completion of the three CIF sections on Demographics, Breast Health Information (e.g. mammogram history), and Correlates of Breast Health (e.g., smoking behavior, alcohol consumption), we found that clients were between 3.2 and 7.2 times more likely to complete the sections via ACASI as opposed to SAPI.

HIV infection, sexual risk behaviour and condom use in the Belize defense force

This study is the first Biological and Behavioral Surveillance Survey to be conducted among personnel in the Belize Defense Force. The purpose of the study was to understand the prevalence of HIV infection and risk behaviours, and to identify key correlates of sexual risk behaviours. A representative sample of personnel underwent serological testing and an Audio Computer-Assisted Self Interview. Of those sampled, 351 completed a blood test and 334 completed a behavioural interview. The prevalence of HIV was 1.14%. Twelve percent had ever reported being diagnosed with a sexually transmitted infection (STI) or screened positive for HIV infection. The odds of ever having an STI/HIV were higher among those who had less education, those who had sex with a commercial sex worker (CSW), those who ever engaged in receptive anal sex and those with post-traumatic stress disorder (PTSD). Alcohol abuse and PTSD were prevalent and associated with HIV risk behaviours. These results are being used to inform current prevention efforts.

Changing coverage of domestic violence murders: a longitudinal experiment in participatory communication

Stressing relation-building and participatory communication approaches, the Rhode Island Coalition against Domestic Violence worked with journalists to develop a best practices handbook on news coverage of domestic violence murders. This study compares print coverage of domestic violence murders prehandbook (1996-1999) and posthandbook (2000-2002). Significant changes include increased labeling of the murder of intimates as domestic violence and doubled usage of advocates as sources. As a result, domestic violence murders, previously framed as unpredictable private tragedies, are more commonly framed posthandbook as social problems warranting public intervention. The authors conclude that relation-building approaches can affect news cultures and public discourse when conducted in conjunction with comprehensive participatory communications strategies.