Why the Indian Health Care Improvement Act Has Failed to Effectively Fund Workforce Development for the Indian Health Service

The Indian Health Service (IHS) faces severe workforce shortages due to underfunding and underdevelopment of clinical training programs. Unlike other direct federal health care systems that have implemented clinical training paradigms as central parts of their success, the IHS has no formalized process for developing such programs internally or in partnership with academic institutions. While the Indian Health Care Improvement Act (IHCIA) authorizes mechanisms by which the IHS can support overall workforce development, a critical portion of the act (U.S. Code 1616p) intended for developing clinical training programs within the agency remains unfunded. Here, we review the funding challenges of the IHCIA, as well as its authorized and funded workforce development programs that have only partially addressed workforce shortages. We propose that through additional funding to 1616p, the IHS could implement clinical training programs needed to prepare a larger workforce more capable of meeting the needs of American Indian/Alaska Native communities.

Envisioning health equity for American Indian/Alaska Natives: a unique HIT opportunity

The Indian Health Service provides care to remote and under-resourced communities in the United States. American Indian/Alaska Native patients have some of the highest morbidity and mortality among any ethnic group in the United States. Starting in the 1980s, the IHS implemented the Resource and Patient Management System health information technology (HIT) platform to improve efficiency and quality to address these disparities. The IHS is currently assessing the Resource and Patient Management System to ensure that changing health information needs are met. HIT assessments have traditionally focused on cost, reimbursement opportunities, infrastructure, required or desired functionality, and the ability to meet provider needs. Little information exists on frameworks that assess HIT legacy systems to determine solutions for an integrated rural healthcare system whose end goal is health equity. This search for a next-generation HIT solution for a historically underserved population presents a unique opportunity to envision and redefine HIT that supports health equity as its core mission.

Innovating for Transformation in First Nations Health Using Community-Based Participatory Research

Community-based participatory research (CBPR) provides the opportunity to engage communities for sustainable change. We share a journey to transformation in our work with eight Manitoba First Nations seeking to improve the health of their communities and discuss lessons learned. The study used community-based participatory research approach for the conceptualization of the study, data collection, analysis, and knowledge translation. It was accomplished through a variety of methods, including qualitative interviews, administrative health data analyses, surveys, and case studies. Research relationships built on strong ethics and protocols to enhance mutual commitment to support community-driven transformation. Collaborative and respectful relationships are platforms for defining and strengthening community health care priorities. We further discuss how partnerships were forged to own and sustain innovations. This article contributes a blueprint for respectful CBPR. The outcome is a community-owned, widely recognized process that is sustainable while fulfilling researcher and funding obligations.

At the Bedside: Traditional Navajo practitioners in a patient-centered health care model

The growing national racial and ethnic diversity has created a greater need for health care delivery systems and health care providers to be more responsive to unique patient needs, that goes beyond meeting the immediate health problems to include attention to other critical component of patient care that take into account cultural competency such as health literacy, health beliefs and behaviors, cultural practices, etc.

A Profile of Indian Health Service Emergency Departments

STUDY OBJECTIVE

The Indian Health Service provides health care to eligible American Indians and Alaskan Natives. No published data exist on emergency services offered by this unique health care system. We seek to determine the characteristics and capabilities of Indian Health Service emergency departments (EDs).

METHODS

All Indian Health Service EDs were surveyed about demographics and operational characteristics for 2014 with the National Emergency Department Inventory survey (available at http://www.emnet-nedi.org/).

RESULTS

Of the forty eligible sites, there were 34 respondents (85% response rate). Respondents reported a total of 637,523 ED encounters, ranging from 521 to 63,200 visits per site. Overall, 85% (95% confidence interval 70% to 94%) had continuous physician coverage. Of all physicians staffing the ED, a median of 13% (interquartile range 0% to 50%) were board certified or board prepared in emergency medicine. Overall, 50% (95% confidence interval 34% to 66%) of respondents reported that their ED was operating over capacity.

CONCLUSION

Indian Health Service EDs varied widely in visit volume, with many operating over capacity. Most were not staffed by board-certified or -prepared emergency physicians. Most lacked access to specialty consultation and telemedicine capabilities.

Development of an interdisciplinary pre-matriculation program designed to promote medical students' self efficacy

BACKGROUND AND OBJECTIVES

A four-week interdisciplinary pre-matriculation program for Native American and rural medical students was created and its impact on students' transition to medical school was assessed. The program extends the goals of many pre-matriculation programs by aiming to increase not only students' understanding of basic science knowledge, but also to build student self-efficacy through practice with medical school curricular elements while developing their academic support networks.

DESIGN

A mixed method evaluation was used to determine whether the goals of the program were achieved (n = 22). Student knowledge gains and retention of the microbiology content were assessed using a microbiology concept inventory. Students participated in focus groups to identify the benefits of participating in the program as well as the key components of the program that benefitted the students.

RESULTS

Program participants showed retention of microbiology content and increased confidence about the overall medical school experience after participating in the summer program.

CONCLUSIONS

By nurturing self-efficacy, participation in a pre-matriculation program supported medical students from Native American and rural backgrounds during their transition to medical school.

ABBREVIATIONS

CAIMH: Center of American Indian and Minority Health; MCAT: Medical College Admission Test; PBL: Problem based learning; UM MSD: University of Minnesota Medical School Duluth.

Violence Against American Indian Women and the Services-Training-Officers-Prosecutors Violence Against Indian Women (STOP VAIW) Program

When Congress appropriated funds to developways to reduce violence against American Indianwomen, tribal elders faced a challenging task: findways to cooperate with various tribal and nontribal criminal justice agencies and navigate the maze of law enforcement authority. An evaluative study was conducted of these programs and the different approaches used to help keep women safe by American Indian tribal governments. This study found that the tribes rose to the challenge; the moneywas making a difference. The grants to stop violence against Indian women have made a significant impact in the 134 native communities that received awards.

The Politics of Native American Health Care and the Affordable Care Act

This article examines an important but largely overlooked dimension of the Patient Protection and Affordable Care Act (ACA), namely, its significance for Native American health care. The author maintains that reading the ACA against the politics of Native American health care policy shows that, depending on their regional needs and particular contexts, many Native Americans are well-placed to benefit from recent Obama-era reforms. At the same time, the kinds of options made available by the ACA constitute a departure from the service-based (as opposed to insurance-based) Indian Health Service (IHS). Accordingly, the author argues that ACA reforms--private marketplaces, Medicaid expansion, and accommodations for Native Americans--are best read as potential "supplements" to an underfunded IHS. Whether or not Native Americans opt to explore options under the ACA will depend in the long run on the quality of the IHS in the post-ACA era. Beyond understanding the ACA in relation to IHS funding, the author explores how Native American politics interacts with the key tenets of Obama-era health care reform--especially "affordability"--which is critical for understanding what is required from and appropriate to future Native American health care policy making.

Pursuing the Triple Aim: The First 7 Years

POLICY POINTS: In 2008, researchers at the Institute for Healthcare Improvement (IHI) proposed the Triple Aim, strategic organizing principles for health care organizations and geographic communities that seek, simultaneously, to improve the individual experience of care and the health of populations and to reduce the per capita costs of care for populations. In 2010, the Triple Aim became part of the US national strategy for tackling health care issues, especially in the implementation of the Patient Protection and Affordable Care Act (ACA) of 2010. Since that time, IHI and others have worked together to determine how the implementation of the Triple Aim has progressed. Drawing on our 7 years of experience, we describe 3 major principles that guided the organizations and communities working on this endeavor: creating the right foundation for population management, managing services at scale for the population, and establishing a learning system to drive and sustain the work over time.

CONTEXT

In 2008, researchers at the Institute for Healthcare Improvement (IHI) described the Triple Aim as simultaneously "improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations." IHI and its close colleagues had determined that both individual and societal changes were needed.

METHODS

In 2007, IHI began recruiting organizations from around the world to participate in a collaborative to implement what became known as the Triple Aim. The 141 participating organizations included health care systems, hospitals, health care insurance companies, and others closely tied to health care. In addition, key groups outside the health care system were represented, such as public health agencies, social services groups, and community coalitions. This collaborative provided a structure for observational research. By noting the contrasts between the contexts and structures of those sites in the collaborative that progressed and those that did not, we were able to develop an ex post theory of what is needed for an organization or community to successfully pursue the Triple Aim.

FINDINGS

Drawing on our 7 years of experience, we describe the 3 major principles that guided the organizations and communities working on the Triple Aim: creating the right foundation for population management, managing services at scale for the population, and establishing a learning system to drive and sustain the work over time.

CONCLUSIONS

The concept of the Triple Aim is now widely used, because of IHI's work with many organizations and also because of the adoption of the Triple Aim as part of the national strategy for US health care, developed during the implementation of the Patient Protection and Affordable Care Act of 2010. Even those organizations working on the Triple Aim before IHI coined the term found our concept to be useful because it helped them think about all 3 dimensions at once and organize their work around them.

The Indian Health Service Model From the Treatment Perspective

The nonprofit dental delivery model is appropriate for the needs of specific patient populations. The Indian Health Service is an example of how care can be provided where traditional fee-for-service and indemnity mechanisms may be insufficient. Separating care from management in this context gives dentists greater power over individual treatment decisions, increased choice of patient-relevant care options, and control over development of the practice model and its evolution. The needs of various populations groups and the funding or profit model inevitably influence the composition of the dental team and assignment of dental duties.

Partnering in research: a national research trial exemplifying effective collaboration with American Indian Nations and the Indian Health Service

Despite the fact that numerous major public health problems have plagued American Indian communities for generations, American Indian participation in health research traditionally has been sporadic in many parts of the United States. In 2002, the University of Oklahoma Health Sciences Center (Oklahoma City, Oklahoma) and 5 Oklahoma American Indian research review boards (Oklahoma City Area Indian Health Service, Absentee Shawnee Tribe, Cherokee Nation, Chickasaw Nation, and Choctaw Nation) agreed to participate collectively in a national research trial, the Treatment Options for Type 2 Diabetes in Adolescence and Youth (TODAY) Study. During that process, numerous lessons were learned and processes developed that strengthened the partnerships and facilitated the research. Formal Memoranda of Agreement addressed issues related to community collaboration, venue, tribal authority, preferential hiring of American Indians, and indemnification. The agreements aided in uniting sovereign nations, the Indian Health Service, academics, and public health officials to conduct responsible and ethical research. For more than 10 years, this unique partnership has functioned effectively in recruiting and retaining American Indian participants, respecting cultural differences, and maintaining tribal autonomy through prereview of all study publications and local institutional review board review of all processes. The lessons learned may be of value to investigators conducting future research with American Indian communities.

Pediatric emergency care capabilities of Indian Health Service emergency medical service agencies serving American Indians/Alaska Natives in rural and frontier areas

INTRODUCTION

In the USA, the emergency medical services (EMS) system is vital for American Indians and Alaska Natives, who are disproportionately burdened by injuries and diseases and often live in rural areas geographically far from hospitals. In rural areas, where significant health disparities exist, EMS is often a primary source of healthcare providing a safety net for uninsured individuals or families who otherwise lack access to health-related services. EMS is frequently the first entry point for children and their families into the healthcare system. The Indian Health Service (IHS) supports the federally funded, tribally operated EMS agencies to help meet the affiliated American Indian and Alaska Natives' pre-hospital needs. While periodic assessments of state EMS agencies capabilities to care for children occur, it appears a systematic assessment of IHS EMS agencies in regards to children had not been previously conducted.

METHODS

A consensus process, involving stakeholders, was used to identify topic areas for a survey for assessing the pediatric capabilities of IHS EMS. The survey was sent to 75 of 88 IHS EMS agency contacts.

RESULTS

Sixty-one agencies (81%) responded. Nine agencies (15%) did not have a medical director. Agencies without a medical director were less likely to report the availability of online (p=0.1) or offline (p<0.01) pediatric medical direction. Half (51%) of the agencies had a mass casualties plan; however, 29% reported responding to a mass casualty incident, involving a large number of pediatric patients, that overwhelmed their service. Most agencies were well integrated with their state EMS system with almost all (95%) collecting EMS patient care data and 47% using national standard data elements.

CONCLUSIONS

In some areas, IHS EMS agencies did not have the infrastructure to treat pediatric patients during day-to-day operations as well as disasters. Similar to operational challenges faced by rural EMS agencies, the IHS agencies lacked a medical director, were unable to provide pediatric continuing education, and were overwhelmed during mass casualty incidents. Moreover, the overall ratio of IHS EMS to service population is almost double that for other EMS agencies. In other areas, agencies were well integrated with their state EMS system. One possible solution to increase capabilities to care for pediatric patients is combining and sharing of common resources including medical directors with their state EMS systems and authorities.

Financing American Indian health care: impacts and options for improving access and quality

(1) Indian Health Service (HIS) per patient funding is less than half of national per capita health spending, and declined further between 2003 and 2006. (2) Under-funding of the IHS system has led to explicit rationing of services to American Indian and Alaska Native patients, with many specialized services provided only for "life or limb threatening" conditions. (3) IHS patients report experiencing access barriers and rate the quality of care process substantially lower than do Medicaid beneficiaries, but most indicate they prefer to use IHS for their health care. (4) Options to increase the funding for American Indian and Alaska Native health care exist, but would impose higher costs on federal and state budgets and are unlikely to be feasible in the current economic environment. However, IHS might be able to make certain organizational changes that would increase efficiency and its ability to extend existing funding to cover more services.

Land of opportunity. Roubideaux takes over at a time when stimulus funding and a proposed boost to the agency's budget could be forthcoming. However, she still says her main concern is that IHS is 'underresourced' and 'underfunded'

2009 brought good news for the Indian Health Service, with a boost to its budget and $500 million in stimulus funding. The new director, Yvette Roubideaux, says it's a good start for an underfunded agency. But some think the stimulus money is unfairly targeting two states: Alaska and South Dakota. Jim Roberts, left, calls it a "boondoggle".

A service-learning elective in Native American culture, health and professional practice

OBJECTIVES

To evaluate the success of an elective course in Native American culture, health, and service-learning in fostering interest in experiences and careers with the USPHS Indian Health Service (IHS), and in shaping reflective practitioners.

DESIGN

Students conducted readings, kept reflective journals, and engaged in discussions with Native American and non-Native American speakers. Students orally presented a Native American health issue and spent their fall break in Chinle, Ariz, providing social and healthcare services to the Diné under the supervision of IHS pharmacists. Opportunities for additional IHS experiences were discussed, as was discerning the Creator's call to a professional life of service.

ASSESSMENT

Thirteen of 15 students who had completed the service-learning course by January 2007 responded to a brief survey indicating that not only were the course objectives met, but the experiences had a lasting impact on professional mindset and career plans.

CONCLUSION

The course had a lasting impact on students' understanding of Native American social and health care issues, and on how they will practice their profession and live their lives.

Project ECHO: linking university specialists with rural and prison-based clinicians to improve care for people with chronic hepatitis C in New Mexico

Project Extension for Community Healthcare Outcomes (Project ECHO) is a telemedicine and distance-learning program designed to improve access to quality health care for New Mexicans with hepatitis C. Project ECHO links health-care providers from rural clinics, the Indian Health Service, and prisons with specialists at the University of New Mexico. At weekly clinics, partners present and discuss patients with hepatitis C with specialists. Partners can receive continuing education credits for participating. Since June 2003, 173 hepatitis C clinics have been conducted with 1,843 case presentations. Partners have received 390 hours of training and 2,997 hours of continuing education credits. And in 2006, the State Legislature approved $1.5 million in annual funding for the project. Project ECHO has increased access to state-of-the art hepatitis C virus care for patients living in rural areas or prisons. Because of its success with hepatitis C, this project is being expanded to other chronic medical conditions.

Future public health delivery models for Native American tribes

BACKGROUND

More and more Native American tribes are assuming control of their own public health care delivery systems by contracting the functions of the Indian Health Service (IHS) through the provisions of P.L. (public law) 93-638, the Indian Self-Determination and Education Assistance Act. In doing this, some Native American tribes are making decisions to create or plan their own departments of public health. In Arizona, the Gila River Indian Community has already established its own department of public health and the Navajo Nation is in the planning stages of establishing its own department of public health.

METHODS AND RESULTS

This paper proposes three public health organizational delivery models to meet the public health needs of small, medium, and large Native American tribes. Information for these models was derived from interviews with officials associated with the Arizona Department of Health Services and leaders of Native American tribes. These models progress in size and complexity as we move from small to medium to large tribes.

CONCLUSIONS

(a) service delivery should focus on both preventative and curative services; (b) services should be developed with input from the underserved population; (c) members of underserved populations should be trained to provide service to their communities; (d) one model of health service delivery will not be appropriate for all underserved populations; and (e) different models are required to respond to differing cultures, populations, and geographic locations.

Implementation and use of an electronic health record within the Indian Health Service

OBJECTIVES

There are limited data regarding implementing electronic health records (EHR) in underserved settings. We evaluated the implementation of an EHR within the Indian Health Service (IHS), a federally funded health system for Native Americans.

DESIGN

We surveyed 223 primary care clinicians practicing at 26 IHS health centers that implemented an EHR between 2003 and 2005.

METHODS

The survey instrument assessed clinician attitudes regarding EHR implementation, current utilization of individual EHR functions, and attitudes regarding the use of information technology to improve quality of care in underserved settings. We fit a multivariable logistic regression model to identify correlates of increased utilization of the EHR.

RESULTS

The overall response rate was 56%. Of responding clinicians, 66% felt that the EHR implementation process was positive. One-third (35%) believed that the EHR improved overall quality of care, with many (39%) feeling that it decreased the quality of the patient-doctor interaction. One-third of clinicians (34%) reported consistent use of electronic reminders, and self-report that EHRs improve quality was strongly associated with increased utilization of the EHR (odds ratio 3.03, 95% confidence interval 1.05-8.8). The majority (87%) of clinicians felt that information technology could potentially improve quality of care in rural and underserved settings through the use of tools such as online information sources, telemedicine programs, and electronic health records.

CONCLUSIONS

Clinicians support the use of information technology to improve quality in underserved settings, but many felt that it was not currently fulfilling its potential in the IHS, potentially due to limited use of key functions within the EHR.

A socioecological approach to improving mammography rates in a tribal community

This article highlights the processes and intermediate outcomes of a pilot project to increase mammography rates of women in an American Indian tribe in New Mexico. Using a socioecological framework and principles of community-based participatory research, a community coalition was able to (a) bolster local infrastructure to increase access to mammography services; (b) build public health knowledge and skills among tribal health providers; (c) identify community-specific knowledge, attitudes, and beliefs related to breast cancer; (d) establish interdependent partnerships among community health programs and between the tribe and outside organizations; and (e) adopt local policy initiatives to bolster tribal cancer control. These findings demonstrate the value of targeting a combination of individual, community, and environmental factors, which affect community breast cancer screening rates and incorporating cultural strengths and resources into all facets of a tribal health promotion intervention.

'Snag bags': adapting condoms to community values in Native American communities

HIV/AIDS researchers working among Native Americans have consistently noted resistance to discussions of sexuality and the distribution of condoms. This resistance is inspired by long held values about shame and public discussions of sexuality. Also, American Indians have been reluctant to welcome public discussions of HIV/AIDS and sexuality from external entities, such as governmental agencies. As a result, Native peoples have some of the lowest documented condom use rates. However, innovations in culturally integrating condoms and safe sex messages into Native cultural ideals are proving beneficial. One such innovation is the snag bag, which incorporates popular Native sexual ideology while working within local ideals of shame to distribute condoms and safe sex materials to sexually active young people and adults. Using snag bags as an example, this research proposes that an effective approach to HIV prevention among Native peoples is not cultural sensitivity but cultural integration. That is, HIV prevention strategies must move beyond the empty promise of merely culturally-sensitizing ideas about disease cause. Instead of simply 'translating' HIV/AIDS programming into Native culture, prevention strategies must be integrated by Native peoples into their own disease theories and contemporary culture.

Using mail to reach patients seen at an urban health care facility

Urban American Indians/Alaska Natives (AI/ANs) are highly mobile, and little is known about ways to include them in research or clinical activities. We evaluated postal mailings as a means of reaching patients seen at an urban Indian health care facility (60% of whom were AI/AN) and identified factors associated with receipt of mail. As part of a clinical trial, a Native art calendar was sent via first class mail to 5,633 clients seen at the urban Indian clinic during the prior two years. A multi-step address verification process was conducted, including telephone contacts, Web searches, and in-person visits. Logistic regressions examined the association of client characteristics with accurate addresses. Based on initial mailings and in-person location efforts, we estimated that only 61% of clients actually received the calendars. The multi-step address verification process was significantly less likely to identify working addresses for clients who were AI/AN and clients who were seen more than 3 months before the study. Reaching urban AI/ANs for research activities and health care is difficult. Innovative strategies are needed to locate this highly mobile and understudied population.

Forty years in partnership: the American Academy of Pediatrics and the Indian Health Service

Fifty years ago, American Indian and Alaska Native children faced an overwhelming burden of disease, especially infectious diseases such as pneumonia, meningitis, tuberculosis, hepatitis A and B, and gastrointestinal disease. Death rates of American Indian/Alaska Native infants between 1 month and 1 year were much higher than in the US population as a whole, largely because of these infectious diseases. The health care of American Indian/Alaska Native patients was transferred to the Department of Health, Education, and Welfare in 1955 and placed under the administration of an agency soon to be known as the Indian Health Service. The few early pediatricians in the Indian Health Service recognized the severity of the challenges facing American Indian/Alaska Native children and asked for help. The American Academy of Pediatrics responded by creating the Committee on Indian Health in 1965. In 1986 the Committee on Native American Child Health replaced the Committee on Indian Health. Through the involved activity of these committees, the American Academy of Pediatrics participated in and influenced Indian Health Service policies and services and, combined with improved transportation, sanitation, and access to vaccines and direct services, led to vast improvements in the health of American Indian/Alaska Native children. In 1965, American Indian/Alaska Native postneonatal mortality was more than 3 times that of the general population of the United States. It is still more than twice as high as in other races but has decreased 89% since 1965. Infectious diseases, which caused almost one fourth of all American Indian/Alaska Native child deaths in 1965, now cause <1%. The Indian Health Service and tribal health programs, authorized by the Indian Self-Determination and Education Assistance Act of 1976 (Pub L. 93-638), continue to seek American Academy of Pediatrics review and assistance through the Committee on Native American Child Health to find and implement interventions for emerging child health problems related to pervasive poverty of many American Indian/Alaska Native communities. Acute infectious diseases that once were responsible for excess morbidity and mortality now are replaced by excess rates resulting from harmful behaviors, substance use, obesity, and injuries (unintentional and intentional). Through strong working partnerships such as that of the American Academy of Pediatrics and the Indian Health Service, progress hopefully will occur to address this "new morbidity." In this article we document the history of the Indian Health Service and the American Academy of Pediatrics committees that have worked with it and present certain statistics related to American Indian/Alaska Native child health that show the severity of the health-status disparities challenging American Indian/Alaska Native children and youth.

Effect of a national vaccine shortage on vaccine coverage for American Indian/Alaska Native children

OBJECTIVES

We determined the effect of national vaccine shortages on coverage with 4 doses of diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine for American Indian/Alaska Native (AIAN) children.

METHODS

Data on DTaP coverage for children aged 19 to 27 months were abstracted from Indian Health Service (IHS) immunization reports. Coverage with the fourth DTaP dose (DTaP4) was compared for different periods to determine coverage levels before, during, and after the shortage. Data were stratified geographically to determine regional variation.

RESULTS

AIAN children experienced a significant decline (14.8%) in DTaP4 coverage during the shortage. Considerable variation was seen among IHS regions (declines ranged from 4.5% to 26.5%).

CONCLUSIONS

AIAN children included in IHS immunization reports experienced a greater decline in DTaP4 coverage during the shortage than the decline reported nationally for children receiving vaccine at public clinics (14.8% vs 6%). Variations in the decline in coverage highlight possible inequities in vaccine supply and distribution and in implementation of vaccine shortage recommendations. We must identify ways to ensure more equitable vaccine distribution and consistent implementation of vaccine recommendations to protect all children from vaccine-preventable diseases.

Redeeming hollow promises: the case for mandatory spending on health care for American Indians and Alaska Natives

The reliance on discretionary spending for American Indian/ Alaska Native health care has produced a system that is insufficient and unreliable and is associated with ongoing health disparities. Moreover, the gap between mandatory spending on a Medicare beneficiary and discretionary spending on an American Indian/Alaska Native beneficiary has grown dramatically, thus compounding the problem. The budget classification for American Indian/Alaska Native health services should be changed, and health care delivery to this population should be designated as mandatory spending. If a correct structure is in place, mandatory spending is more likely to provide adequate funding that keeps pace with changes in costs and need.

Bridging disparity: a multidisciplinary approach for influenza vaccination in an American Indian community

OBJECTIVES

The Whiteriver Service Unit (WRSU) used proven effective methods to conduct an influenza vaccination campaign during the 2002-2003 influenza season to bridge the vaccination gap between American Indians and Alaska Natives and the US population as a whole.

METHODS

In our vaccination program, we used a multidisciplinary approach that included staff and community education, standing orders, vaccination of hospitalized patients, and employee, outpatient, community, and home vaccinations without financial barriers.

RESULTS

WRSU influenza vaccination coverage rates among persons aged 65 years and older, those aged 50 to 64 years, and those with diabetes were 71.8%, 49.6%, and 70.2%, respectively, during the 2002-2003 influenza season. We administered most vaccinations to persons aged 65 years and older through the outpatient clinics (63.6%) and public health nurses (30.0%). The WRSU employee influenza vaccination rate was 72.8%.

CONCLUSIONS

We achieved influenza vaccination rates in targeted groups of an American Indian population that are comparable to or higher than rates in other US populations. Our system may be a useful model for other facilities attempting to bridge disparity for influenza vaccination.

Building true capacity: indigenous models for indigenous communities

Within the past 2 decades, community capacity building and community empowerment have emerged as key strategies for reducing health disparities and promoting public health. As with other strategies and best practices, these concepts have been brought to indigenous (American Indian and Alaska Native) communities primarily by mainstream researchers and practitioners. Mainstream models and their resultant programs, however, often have limited application in meeting the needs and realities of indigenous populations. Tribes are increasingly taking control of their local health care services. It is time for indigenous people not only to develop tribal programs but also to define and integrate the underlying theoretical and cultural frameworks for public health application.

Suicide prevention efforts in one area of Indian Health Service, USA

Suicide is the second leading cause of death in young Indian people. USA's Indian Health Service is responsible for the health of the people; a structured system and services are provided. These services include surveillance and suicide investigation, to allow for better understanding. This article presents the current epidemiology on suicide for American Indians and Alaskan Natives (AI/AN). The data show a very high rate in the young, especially males. Beyond the general, the article offers a unique look into a suicidal AI/AN young person, through the psychological autopsy. A case illustration, E.S., a 16-year-old male who died by suicide, is outlined. Discussion, the author's words, and current efforts of Indian Health Services are presented, but it is concluded that much greater effort is needed.

Suicidal ideation among American Indian youths

This study examined correlates of suicidal ideation among 212 American Indian youth who lived on or near three reservations in the upper Midwestern United States. The youths were, on average, 12 years old, and 9.5% reported current thoughts about killing themselves. Females were over 2 times more likely than males to think about suicide. Multivariate logistic regression results indicated that gender, enculturation, negative life events, perceived discrimination, self-esteem, and drug use were related to the likelihood of thinking about suicide. Drug use was the strongest correlate of suicidal ideation, and both enculturation and perceived discrimination emerged as important culturally specific variables. It was suggested that suicide prevention programs should draw on the strengths of American Indian culture.

Student and resident education and rural practice in the Southwest Indian Health Service: a physician survey

BACKGROUND AND OBJECTIVES

The Indian Health Service (IHS) is an educational rotation site for numerous medical students and residents. These IHS rotations may be an important factor in recruitment and retention of physicians to the IHS. We describe the combined number of student/resident rotations in the Southwest IHS and their influence on recruitment and retention. We also analyze factors related to choice of rural practice in the IHS.

METHODS

We conducted a survey of clinical directors and IHS physicians in Arizona and New Mexico.

RESULTS

Twenty (87%) clinical director surveys and 289 (66%) physician surveys were returned. More than 400 students/residents participate in rotations annually in the IHS in Arizona and New Mexico. Eighty-four percent of clinical directors feel that educational programs are important to recruitment. Forty-five percent of current IHS physicians participated in IHS rotations as students or residents, and 87% feel that rotating influenced their decision to join the IHS. Eighty percent of IHS physicians who teach feel that working with students and residents improves their job satisfaction. Seventy-five percent of respondents practice in rural areas. Rural medical student and resident rotations are associated with subsequent rural practice.

CONCLUSIONS

Many medical students and residents rotate in the Southwest IHS. Clinical directors state that these rotations are helpful to recruitment, and IHS physicians who rotated feel it was important in their decision to join the IHS. IHS clinicians feel that teaching improves job satisfaction.

Assessment of public health workforce bioterrorism and emergency preparedness readiness among tribes in Washington State: a collaborative approach among the Northwest Center for Public Health Practice, the Northwest Portland Area Indian Health Board, and the Washington State Department of Health

This article examines the collaboration, methodology, results, and lessons learned stemming from the experience of a unique university, state, and tribal collaborative model for public health emergency preparedness assessment activities. This collaborative model may be applicable to other public health preparedness efforts, as well as the broader range of general public health or workforce development partnerships between state, local, and tribal health departments and academic institutions.

Environmental Assessment of the Indian Health Service

The Indian Health Service (IHS), an agency within the U.S. Department of Health and Human Services, was responsible for providing federal health services to 1.51 million American Indian and Alaska Natives in 2000. Several opportunities related to health care exist for the IHS: potential public and private collaborations, continuation of the Clinton Administration's legacy of meaningful tribal consultation, and increasing the numbers of American Indian physicians, nurses, and other health related professionals. Modifications in federal programs such as Medicare and Medicaid pose a serious threat to the IHS because the IHS relies on these programs to offset the overall lack of funding. This article provides a framework for identifying the ways in which the external environment affects and determines the IHS' strategic responses to ensure competitiveness within the U.S. health care market. Value chain analysis will be used to evaluate the competitive advantages and disadvantages of the current IHS internal environment.

Assessment of the National Library of Medicine's health disparities plan: a focus on Native American outreach

OBJECTIVES

Overcoming health disparities between majority and minority populations is a significant national challenge. This paper assesses outreach to Native Americans (American Indians, Alaska Natives, and Native Hawaiians) by the National Library of Medicine (NLM). A companion paper details NLM's portfolio of Native American outreach projects.

METHOD

NLM's Native American outreach is assessed in light of the presentations at a community-based health information outreach symposium and the goals set by NLM's plan to reduce health disparities.

RESULTS

NLM's current portfolio of Native American outreach projects appears most advanced in meeting the goal set in area 1 of the health disparities plan, "Promote use of health information by health professionals and the public." NLM's portfolio also shows significant strength and good progress regarding area 2 of the plan, "Expand partnerships among various types of libraries and community-based organizations." The portfolio is weaker in area 3, "Conduct and support informatics research." More knowledge-building efforts would benefit NLM, the National Network of Libraries of Medicine, and Native American and community-based organizations.

IMPLICATIONS

The current Native American outreach portfolio should be continued, but new approaches are needed for evaluating Native American outreach and for forging collaborations with Native American groups, approaches grounded in consultation and mutual understanding of needs and perspectives.

Taking well-child care into the 21st century: a novel, effective method for improving parent knowledge using computerized tutorials

BACKGROUND

Despite expert panel recommendations, few pediatric providers administer sufficient anticipatory guidance and educational counseling during well-child visits, largely owing to lack of time.

OBJECTIVES

To design a waiting room educational kiosk that uses interactive, self-guided, computerized tutorials to give anticipatory guidance to parents at the 6-week and 4-month well-child visits, and assess impact on parent knowledge. The intervention required no additional provider time, and automatically printed a summary for the medical record.

SETTING

A government-funded hospital serving Navajo patients in New Mexico.

METHODS

After a well-child visit, knowledge regarding issues such as fever management, dental care, sleep position, nutrition, and car seat use was tested in a group of parents receiving standard care (control), and a group using the computerized tutorials in addition to standard care (intervention).

RESULTS

Fifty-two parents in the control group and 49 parents in the intervention group completed the knowledge assessment. Ninety-five percent of intervention subjects completed the computerized tutorial without clinic staff involvement. Compared with the control group, the intervention group had superior knowledge in all tested areas. The percentage of correct responses to all questions was higher for the intervention group in the following categories: car seat use (49% vs 31%, P<.01), dental care (80% vs 27%, P<.001), and nutrition (43% vs 21%, P<.001). Among parents of 6-week-old infants, a greater number of parents in the intervention group identified fever as 100.4 degrees F or higher (86% vs 50%, P<.001), and fewer replied that they would give antipyretics to a febrile child younger than 3 months old without consulting a provider (52% vs 100%, P<.001). The percentage of parents with a perfect score or only one question wrong on the 21-item test was 17-fold higher in the intervention group (P<.001).

CONCLUSION

Computerized anticipatory guidance at well-child visits increases knowledge over printed materials alone and is usable by the majority of parents.

Health service access, use, and insurance coverage among American Indians/Alaska Natives and Whites: what role does the Indian Health Service play?

OBJECTIVES

We compared access and utilization of health services among American Indians/Alaska Natives (AIANs) with that among non-Hispanic Whites.

METHODS

We used data from the 1997 and 1999 National Survey of America's Families to estimate odds ratios for several measures of access and utilization and the effects of Indian Health Service (IHS) coverage.

RESULTS

AIANs had less insurance coverage and worse access and utilization than Whites. Over half of low-income uninsured AIANs did not have access to the IHS. However, among the low-income population, AIANs with only IHS access fared better than uninsured AIANs and as well as insured Whites for key measures but received less preventive care.

CONCLUSIONS

The IHS partially offsets lack of insurance for some uninsured AIANs, but important needs were potentially unmet.

Palliative Care in the Pueblo of Zuni

The American Indian and Alaska Native population is aging and the leading causes of death for those aged 55 and older are chronic diseases such as cancer, heart disease, and the complications of diabetes. There are limited formal palliative care services available to rural and reservation dwelling American Indians and Alaska Natives. This collaboration between a tribally operated home health care agency and a federally operated Indian Health Service hospital, with the support of a palliative care center within an academic medical center, has established a palliative care program in the Pueblo of Zuni. The program is based in the tribal home health agency. Barriers to development included the rural setting with limited professional workforce, competing demands in a small agency, the need for coordination across distinct organizations, and the need to address the dying process in a culturally proficient manner. Family-focused interviews and other techniques were used to tailor the palliative care program to the unique cultural setting. The program has sought to integrate inpatient care of terminally ill patients at the Indian Health Service (IHS) hospital with outpatient hospice care. The initial goal of obtaining certification as a Medicare Hospice provider has not been met and remains a goal. Meanwhile alternative mechanisms for funding the services have been found. The experience of this collaboration suggests that a tribally based, culturally proficient palliative care program can be developed within an American Indian/Alaska Native community and that it can drive the local health system toward improved end-of-life care.

Palliative care: an emerging issue for American Indians and Alaskan Natives

Over 4 million American Indians and Alaskan Natives live in communities that receive health care primarily from the federal Indian Health Service or tribal health programs. Palliative care has only recently been formally addressed for these communities. An Indian Health Service program introduced the topic and several programs are ongoing. Needs for and barriers to palliative care in native peoples' communities are discussed and several successful programs at various stages of development and implementation are described.

Social services: the Navajo way

The development of child welfare services in Indian Country followed enactment of the 1975 Indian Education and Self-Determination Act and the 1978 Indian Child Welfare Act. These acts allow tribal contracting with the Bureau of Indian Affairs (BIA) to provide social services. Because the BIA model has not fit well with Navajo needs, the Navajo Nation Division of Social Services is creating a more holistic case management paradigm for child and family services, which is more congruent with its culture and its rural, sparsely populated land.

Disparities in infant health among American Indians and Alaska natives in US metropolitan areas

OBJECTIVE

To determine geographic variation in urban American Indian and Alaska Native (AI/AN) rates of infant mortality, low birth weight, prenatal care use, and maternal-child health care service availability.

METHODS

This was a retrospective cohort study using data from the 1989 to 1991 birth-death linked database from the National Center for Health Statistics. We examined births from metropolitan areas with a minimum of 300 AI/AN births during the study period. Key outcomes of interest included rates of low birth weight, neonatal mortality, postneonatal mortality, and women receiving inadequate prenatal care using the modified Kessner index. To determine the type of health services tailored to AI/AN mothers residing in these urban areas, we conducted a telephone survey of the 36 urban Indian health programs operating in 1997 using a semistructured survey. Items in the survey included questions about the availability of prenatal and infant health care.

RESULTS

During the 1989 to 1991 study period, there were 72 730 singleton births to AI/AN mothers and/or fathers residing in urban areas, representing 49% of all AI/AN births in the United States. Overall 14.4% of urban AI/AN births were to women who received inadequate care during pregnancy, 5.7% of pregnancies resulted in low birth weight infants, and 11.0 infants died per 1000 live births. Death rates for the neonatal period (5.5 per 1000 births) and postneonatal period (5.4 per 1000 births) were similar. Marked disparity in these indicators exist between pregnancies to AI/AN and white women. Among the 54 metropolitan areas, 46 had a rate ratio (AI/AN: white) for inadequate care of > or =1.5 (range: 0.9-8.5). The mean rate ratios for neonatal and postneonatal mortality were 1.6 (range: 0.3-4.0) and 2.0 (range: 0.5-5.5). There was also considerable geographic variation of AI/AN mortality rates between metropolitan areas in all of the outcomes studied. All of the 20 metropolitan areas with the highest birth counts had some type of direct medical care or outreach services available from an urban clinic targeted toward AI/AN patients.

CONCLUSIONS

Considerable variation also exists among rates of AI/ANs between metropolitan areas. Disparity exists in rates of perinatal outcomes between AI/ANs and whites living in the same metropolitan areas Although AI/AN urban health programs exist in most cities with large birth counts, it seems that many have inadequate resources to meet existing needs to improve perinatal outcomes and infant health.