The Impact of Within-Consultation and Preconsultation Decision Aids for Localized Prostate Cancer on Patient Knowledge: Results of a Patient-Level Randomized Trial

OBJECTIVE

To evaluate the role of timing (either before or during initial consultation) on the effectiveness of decision aids (DAs) to support shared-decision-making in a minority-enriched sample of patients with localized prostate cancer using a patient-level randomized controlled trial design.

METHODS

We conducted a 3-arm, patient-level-randomized trial in urology and radiation oncology practices in Ohio, South Dakota, and Alaska, testing the effect of preconsultation and within-consultation DAs on patient knowledge elements deemed essential to make treatment decisions about localized prostate cancer, all measured immediately following the initial urology consultation using a 12-item Prostate Cancer Treatment Questionnaire (score range 0 [no questions correct] to 1 [all questions correct]), compared to usual care (no DAs).

RESULTS

Between 2017 and 2018, 103 patients-including 16 Black/African American and 17 American Indian or Alaska Native men-were enrolled and randomly assigned to receive usual care (n = 33) or usual care and a DA before (n = 37) or during (n = 33) the consultation. After adjusting for baseline characteristics, there were no statistically significant proportional score differences in patient knowledge between the preconsultation DA arm (0.06 knowledge change, 95% CI -0.02 to 0.12, P = .1) or the within-consultation DA arm (0.04 knowledge change, 95% CI -0.03 to 0.11, P = .3) and usual care.

CONCLUSION

In this trial oversampling minority men with localized prostate cancer, DAs presented at different times relative to the specialist consultation showed no improvement in patient knowledge above usual care.

Perspectives on Conducting Research in Indian Country

BACKGROUND

Certain research principles, framed within an indigenous context, are helpful guideposts to practice ethical, relevant, and sensitive inquiries. It is essential to further adapt research approaches based on the unique geographical, sociopolitical, and cultural attributes of partnering tribal communities. These adaptations are largely shaped by trial and error.

OBJECTIVES

The purpose of this article is to offer the prospective novice nurse researcher lessons that we learned when entering Indian country to conduct research for the first time. As indigenous and nonindigenous researchers, we are not seeking to set down a methodology but rather offer a list of processes, environments, timelines, and barriers that we never learned in didactic, seminar, clinical, practicum, or any other academic setting.

METHODS

We organized a set of memories and thoughts through a series of semistructured iterative sessions specific to our first encounters as researchers in Indian country. We compiled our written responses and field notes from our dialogue, interpreted these data, and organized them into themes. We have reported what we felt would be the most surprising, frequent, or important information to note.

RESULTS

We identified three overarching themes in our collective experience: orientation and negotiation, situating ourselves and our work, and navigating our way. Subthemes included perceiving ourselves as outsiders, negotiating distance and time realities, relying on the goodness of gatekeepers, shaping research questions per community priorities, honing our cross-cultural and intercultural communication skills, discovering the many layers of tribal approval processes, and developing sensibilities and intuition.

DISCUSSION

Our previous experiences as novices leading research projects in Indian country have produced unique sensibilities that may serve to guide nurse researchers who seek to partner with tribal communities.

Resilience in American Indian and Alaska Native Public Health: An Underexplored Framework

OBJECTIVE

To conduct a systematic literature review to assess the conceptualization, application, and measurement of resilience in American Indian and Alaska Native (AIAN) health promotion.

DATA SOURCES

We searched 9 literature databases to document how resilience is discussed, fostered, and evaluated in studies of AIAN health promotion in the United States.

STUDY INCLUSION AND EXCLUSION CRITERIA

The article had to (1) be in English; (2) peer reviewed, published from January 1, 1980, to July 31, 2015; (3) identify the target population as predominantly AIANs in the United States; (4) describe a nonclinical intervention or original research that identified resilience as an outcome or resource; and (5) discuss resilience as related to cultural, social, and/or collective strengths.

DATA EXTRACTION

Sixty full texts were retrieved and assessed for inclusion by 3 reviewers. Data were extracted by 2 reviewers and verified for relevance to inclusion criteria by the third reviewer.

DATA SYNTHESIS

Attributes of resilience that appeared repeatedly in the literature were identified. Findings were categorized across the lifespan (age group of participants), divided by attributes, and further defined by specific domains within each attribute.

RESULTS

Nine articles (8 studies) met the criteria. Currently, resilience research in AIAN populations is limited to the identification of attributes and pilot interventions focused on individual resilience. Resilience models are not used to guide health promotion programming; collective resilience is not explored.

CONCLUSION

Attributes of AIAN resilience should be considered in the development of health interventions. Attention to collective resilience is recommended to leverage existing assets in AIAN communities.

Environmental health and justice and the right to research: institutional review board denials of community-based chemical biomonitoring of breast milk

Recently, conflicts and challenges have emerged regarding environmental justice and research ethics for some indigenous communities. Alaska Community Action on Toxics (ACAT) responded to community requests for breast milk biomonitoring and conceived the Breast Milk Pilot Study (BMPS). Despite having community support and federal and private funding, the BMPS remains incomplete due to repeated disapprovals by the Alaska Area IRB (Institutional Review Board). In this commentary, we explore the consequences of years of IRB denials, in terms of health inequalities, environmental justice, and research ethics. We highlight the greater significance of this story with respect to research in Alaska Native communities, biomonitoring, and global toxics regulation. We offer suggestions to community-based researchers conducting biomonitoring projects on how to engage with IRBs in order to cultivate reflective, context-based research ethics that better consider the needs and concerns of communities.

Posttraumatic stress disorder and symptoms among American Indians and Alaska Natives: a review of the literature

PURPOSE

American Indians and Alaska Natives (AI/ANs) experience high rates of trauma and posttraumatic stress disorder (PTSD). We reviewed existing literature to address three interrelated questions: (1) What is the prevalence of PTSD and PTSD symptoms among AI/ANs? (2) What are the inciting events, risk factors, and co-morbidities in AI/ANs, and do they differ from those in the general U.S. population? (3) Are studies available to inform clinicians about the course and treatment of PTSD in this population?

METHODS

We searched the PubMed and Web of Science databases and a database on AI/AN health, capturing an initial sample of 77 original English-language articles published 1992–2010. After applying exclusion criteria, we retained 37 articles on prevalence of PTSD and related symptoms among AI/AN adults. We abstracted key information and organized it in tabular format.

RESULTS

AI/ANs experience a substantially greater burden of PTSD and related symptoms than U.S. Whites. Combat experience and interpersonal violence were consistently cited as leading causes of PTSD and related symptoms. PTSD was associated with bodily pain, lung disorders, general health problems, substance abuse, and pathological gambling. In general, inciting events, risk factors, and co-morbidities appear similar to those in the general U.S. population.

CONCLUSIONS

Substantial research indicates a strikingly high incidence of PTSD in AI/AN populations. However, inciting events, risk factors, and co-morbidities in AI/ANs, and how they may differ from those in the general population, are poorly understood. Very few studies are available on the clinical course and treatment of PTSD in this vulnerable population.

Drum-Assisted Recovery Therapy for Native Americans (DARTNA): results from a pretest and focus groups

Drum-Assisted Recovery Therapy for Native Americans (DARTNA) is a substance abuse treatment intervention for American Indians/Alaska Natives (AI/ANs). This article provides results from 1) an initial pretest of DARTNA provided to 10 AI/AN patients with histories of substance use disorders, and 2) three subsequent focus groups conducted among AI/AN DARTNA pretest participants, substance abuse treatment providers, and the DARTNA Community Advisory Board. These research activities were conducted to finalize the DARTNA treatment manual; participants also provided helpful feedback which will assist toward this goal. Results suggest that DARTNA may be beneficial for AI/ANs with substance use problems.

Validation of a dietary history questionnaire for American Indian and Alaska Native people

OBJECTIVE

We assessed reliability and relative validity of a self-administered computer-assisted dietary history questionnaire (DHQ) for use in a prospective study of diet, lifestyle, and chronic disease in American Indians in the Dakotas and Southwestern US and Alaska Native people.

DESIGN

Reliability was assessed by one-month test-retest of the dietary history questionnaire. Validity was assessed by comparison of the weighted average of up to 12 monthly 24-hour recalls collected prospectively and a dietary history questionnaire completed in the 13th month.

PARTICIPANTS

Participants were recruited at the baseline visit of the Education and Research Toward Health Study in Alaska, the Northern Plains and the Dakotas.

RESULTS

Reliability (Pearson correlation) of the DHQ ranged from r = 0.43 for vitamin A density to r = 0.90 for energy intake. The association of nutrient and food estimates assessed by 24-hour recalls and the DHQ completed at the end of the year reflected no bias towards recent intake. Macronutrients expressed as density (nutrients per 1000 calories) did appear to be valid (r = 0.50-0.71) as did several micronutrients (range r = .22 to 0.59), fiber (r = 0.51), and servings of red meat (r = 0.67). However, the DHQ overestimated intake and gross amounts of nutrients were not strongly associated with the weighted average of the 24-hour recalls.

CONCLUSIONS

The DHQ developed for estimation of dietary intake in American Indians and Native people in Alaska is reliable. Estimates of nutrient density appeared to have acceptable relative validity for use in epidemiologic studies.

Naltrexone alone and with sertraline for the treatment of alcohol dependence in Alaska natives and non-natives residing in rural settings: a randomized controlled trial

BACKGROUND

Access to specialty alcoholism treatment in rural environments is limited and new treatment approaches are needed. The objective was to evaluate the efficacy of naltrexone alone and in combination with sertraline among Alaska Natives and other Alaskans living in rural settings. An exploratory aim examined whether the Asn40Asp polymorphism of the mu-opioid receptor gene (OPRM1) predicted response to naltrexone, as had been reported in Caucasians.

METHODS

Randomized, controlled trial enrolling 101 Alaskans with alcohol dependence, including 68 American Indians/Alaska Natives. Participants received 16 weeks of either (1) placebo (placebo naltrexone + placebo sertraline), (2) naltrexone monotherapy (50 mg naltrexone + sertraline placebo) and (3) naltrexone + sertraline (100 mg) plus nine sessions of medical management and supportive advice. Primary outcomes included Time to First Heavy Drinking Day and Total Abstinence.

RESULTS

Naltrexone monotherapy demonstrated significantly higher total abstinence (35%) compared with placebo (12%, p = 0027) and longer, but not statistically different, Time to First Heavy Drinking Day (p = 0.093). On secondary measures, naltrexone compared with placebo demonstrated significant improvements in percent days abstinent (p = 0.024) and drinking-related consequences (p = 0.02). Combined sertraline and naltrexone did not differ from naltrexone alone. The pattern of findings was generally similar for the American Indian/Alaska Native subsample. Naltrexone treatment response was significant within the group of 75 individuals who were homozygous for OPRM1 Asn40 allele. There was a small number of Asp40 carriers, precluding statistical testing of the effect of this allele on response.

CONCLUSIONS

Naltrexone can be used effectively to treat alcoholism in remote and rural communities, with evidence of benefit for American Indians and Alaska Natives. New models of care incorporating pharmacotherapy could reduce important health disparities related to alcoholism.

Breastfeeding Prevalence among an Alaskan Inupiat Eskimo Population

Breastfeeding provides valuable immunologic, nutritional, and psychological advantages to infants and is the most desirably complete diet for the infant during the first 6 months of life. The purpose of this exploratory study was to determine the prevalence of breastfeeding in a group of Alaskan Inupiat Eskimos, who live in northern Alaska. A convenience sample of 36 women making up three age cohorts was utilized (women ages 18 to 25, N=11; ages 26 to 40, N=14; ages 41 to 60, N=11). Data collected from these women on their choice of infant-feeding method contributed to measuring the prevalence of breastfeeding. Prevalence was also measured by categorizing the children of these women into three age groups and further classifying them as to how they were fed when they were infants. Statistical analysis was performed utilizing 95% confidence intervals. Results revealed that, in this sample and over the past 20 years, a substantial decline has occurred in the percentage of Inupiat infants exclusively breastfeeding for 6 months or longer. Data also indicated a downward trend in the percentage of mothers between the ages of 26 and 39 who initiate breastfeeding; however, among the mothers aged 18 to 25, data reflected a rising trend.