Honoring our teachings: children's storybooks as indigenous public health practice

Introduction

American Indian and Alaska Native (AIAN) communities continue to flourish and innovate in the face of the COVID-19 pandemic. Storytelling is an important tradition for AIAN communities that can function as an intervention modality. To support the needs of AIAN children and caregivers, we (a collaborative workgroup of Indigenous health researchers) developed a culturally grounded storybook that provides pandemic-related public health guidance and mental health coping strategies woven with Inter-Tribal values and teachings.

Methods

A collaborative workgroup, representing diverse tribal affiliations, met via four virtual meetings in early 2021 to discuss evolving COVID-19 pandemic public health guidance, community experiences and responses to emerging challenges, and how to ground the story in shared AIAN cultural strengths. We developed and distributed a brief survey for caregivers to evaluate the resulting book.

Results

The workgroup iteratively reviewed versions of the storyline until reaching a consensus on the final text. An AI artist from the workgroup created illustrations to accompany the text. The resulting book, titled Our Smallest Warriors, Our Strongest Medicine: Honoring Our Teachings during COVID-19 contains 46 pages of text and full-color illustrations. An online toolkit including coloring pages, traditional language activities, and caregiver resources accompanies the book. We printed and distributed 50,024 physical copies of the book and a free online version remains available. An online survey completed by N = 34 caregivers who read the book with their child(ren) showed strong satisfaction with the book and interest in future books.

Discussion

The development of this storybook provides insights for creative dissemination of future public health initiatives, especially those geared toward AIAN communities. The positive reception and widespread interest in the storybook illustrate how braiding AIAN cultural teachings with public health guidance can be an effective way to disseminate health information. This storybook highlights the importance of storytelling as an immersive learning experience through which caregivers and children connect to family, community, culture, and public health guidance. Culturally grounded public health interventions can be effective and powerful in uplifting AIAN cultural values and promoting health and well-being for present and future generations.

COVID-19 vaccine hesitancy among American Indian and Alaska native college students: the roles of discrimination, historical trauma, and healthcare system distrust

For American Indians and Alaska Native (AIAN) and other communities of color, experiences with discrimination and historical trauma may contribute to healthcare system distrust and negatively affect health care decisions, including vaccination. A saturated path analysis was conducted to examine the direct and indirect associations of thoughts regarding historical losses (of culture, language, and traditional ways) and AIAN racial discrimination with historical loss associated distress, healthcare system distrust, and COVID-19 vaccine hesitancy among AIAN college students (N = 391). Historical loss thoughts and experiences with racial discrimination were strongly associated with each other, and both were uniquely associated with greater historical loss associated distress. In turn, historical loss associated distress was associated with greater healthcare system distrust, which in turn was associated with greater likelihood of being COVID-19 vaccine hesitant. While further research is needed, the findings suggest that to address health disparities for AIAN people it is necessary to consider how to best overcome healthcare system distrust and factors that contribute to it, including historical trauma and contemporary experiences with discrimination.

Understanding the resilience of children living on an American Indian reservation: A mixed methods participatory study

AIM

To explore the resilience of children, six to thirteen years old, living on a Northern Plains American Indian Reservation using a situation specific nursing theory.

BACKGROUND

American Indian and Alaska Native children experience mental health inequities compared to their white peers, including substance use, suicide, depression, and anxiety. Resilience is a strength of children that can be leveraged to improve their mental health.

DESIGN

A parallel convergent mixed methods design.

METHODS

A community advisory board culturally adapted resilience instruments. During two weeks in summer 2022, forty-seven children/caregiver dyads completed surveys about the child's resilience. Descriptive statistics gave the scores of each child's personal, relational, and total resilience. A subset of 20 children participated in a semi-structured interview.

RESULTS

Children scored high on overall resilience, and higher on the relational subscale than the personal subscale. Caregiver survey scores were not significantly correlated with their child's scores and were higher than the children's scores. Qualitative coding revealed six themes of resilience. Integration of data showed a concordance and expansion of the quantitative data across themes.

CONCLUSION

The children reported high resilience supported by a strong ecosystem of relationships. Resilience, as explained through children's voices, corroborated with findings from the surveys.

IMPLICATIONS FOR NURSING

Findings will help nurses across sectors of primary, secondary, and tertiary care create resilience-enhancing interventions and prevent mental health crises in this community.

IMPACT STATEMENT

This findings from this study will inform local mental health interventions on the Reservation. The study provides a reproducible design to adapt to other Indigenous communities.

PUBLIC CONTRIBUTION

A community advisory board was a partner in every stage of the study. Children and caregivers participated in data collection.

CONTRIBUTION TO THE WIDER CLINICAL COMMUNITY

This research provides knowledge that will further social justice efforts within nursing to promote health equity across diverse populations.

Food Security and Food Sovereignty: The Difference Between Surviving and Thriving

Previous research in American Indian and Alaska Native (AI/AN) communities has documented high prevalence of food insecurity. Yet many AI/AN scholars and communities have expressed concerns that the dominant societal conceptions of food security are not reflective of the teachings, priorities, and values of AI/AN communities. Food security initiatives often focus on access to food and, at times, nutrition but little consideration is given to cultural foods, the spirituality carried through foods, and whether the food was stewarded in a way that promotes well-being not just for humans but also for plants, animals, land, and water. Despite the concerns of AI/AN communities that their needs are not centered in dominant societal food conceptualizations and food security programming, the food sovereignty efforts of AI/AN communities have captured national attention as a solution to modern food system inequities. Indigenous Food Sovereignty (IFS) is a holistic approach to food that incorporates values of relationality, reciprocity, and relationships. Fundamental differences exist between food security and food sovereignty, yet dominant society often reduces IFS as a solution to food security, rather than an entirely different food system that is predicated on values that contrast with that of dominant society. Despite calls to decolonize the definition and measurement of food security, we explore whether fixing the concept of food security is a worthy endeavor or whether efforts would be better spent supporting the resurgence and revitalization of AI/AN food values, food knowledge, and community food sovereignty initiatives.

Differences in Breast Cancers Among American Indian/Alaska Native and non-Hispanic Whites in the USA

IMPORTANCE

Breast cancer (BC) death rates have not improved for American Indian/Alaska Native (AI/AN) women, whereas, it has significantly decreased for non-Hispanic White (White) women.

OBJECTIVE

Delineate the differences in patient and tumor characteristics among AI/AN and Whites with BC, and its impact on age and stage at diagnosis as well as overall survival (OS).

METHODS

Hospital-based, cohort study using the National Cancer Database to identify female AI/AN and Whites diagnosed with BC between the years 2004 and 2016.

RESULTS

BC in 6866 AI/AN (0.3%) and 1,987,324 Whites (99.7%) were studied. The median age at diagnosis was 58 for AI/AN and 62 for Whites. AI BC patients traveled double the distance for treatment, lived in lower median income zip codes, had a higher percentage of uninsured, higher comorbidities, lower percentage of Stage 0/I, larger tumor size, greater number of positive lymph nodes, higher proportion of triple negative and HER2-positive BC than Whites. All the above comparisons were significant, p<0.001. Association between patient/tumor characteristics with age and stage at diagnosis was not significantly different between AI/AN and Whites. Unadjusted OS was worse for AI/AN as compared to Whites (HR=1.07, 95% CI=1.01-1.14, p=0.023). After adjustment of all covariates, OS was not different (HR=1.038, 95%CI=0.902-1.195, p=0.601).

CONCLUSION

There were significant differences in patient/tumor characteristics among AI/AN and White BC which adversely impacted OS in AI/AN. However, when adjusted for various covariates, the survival was similar, suggesting that the worse survival in AI/AN is mostly the impact of known biological, socio-economic, and environmental determinants of health.

Social Network Differences Between American Indian Youth Who have Attempted Suicide and Have Suicide Ideation

Suicide is a crucial public health concern for American Indian and Alaska native (AIAN) communities. AIANs have the highest suicide rate compared to all other ethnic groups in the United States. Social relations are a salient fixture of AIAN culture. The primary aims of this study were to describe the personal networks of AI youth that have recently had a suicide attempt or suicidal ideation and to identify key network differences between the two groups. This study uses personal networks collected among AIs living on a reservation in the Southwest. Our sample included 46 American Indians that have recently attempted suicide or had suicidal ideation. We explored social network characteristics of the two groups descriptively as well as comparatively (t-tests). Our findings suggest that AI youth that have attempted suicide nominate more friends in their networks that have used alcohol and drugs compared to the networks of AI youth that have recent suicide ideation. Additionally, AI youth that recently attempted suicide have used alcohol and drugs with their network peers at a higher rate than youth that have had recent suicide ideation. Lastly, AI youth that have attempted suicide recently were significantly more likely to have more nominated friends in their networks that they had reached out to when they were struggling with suicide compared to their peers that have experienced recent suicide ideation. These results indicate a promising method moving forward to identify unique intervention strategies that extend beyond the individual.

Community Health Representative Workforce: Meeting the Moment in American Indian Health Equity

In 2018, the Community Health Representative (CHR) workforce celebrated their 50th year and serve as the oldest and only federally funded Community Health Worker (CHW) workforce in the United States. CHRs are a highly trained, well-established standardized workforce serving the medical and social needs of American Indian communities. Nationally, the CHR workforce consists of ~1,700 CHRs, representing 264 Tribes. Of the 22 Tribes of Arizona, 19 Tribes operate a CHR Program and employ ~250 CHRs, equivalent to ~30% of the total CHW workforce in the state. Since 2015, Tribal CHR Programs of Arizona have come together for annual CHR Policy Summits to dialogue and plan for the unique issues and opportunities facing CHR workforce sustainability and advancement. Overtime, the Policy Summits have resulted in the Arizona CHR Workforce Movement, which advocates for inclusion of CHRs in state and national level dialogue regarding workforce standardization, certification, training, supervision, and financing. This community case study describes the impetus, collaborative process, and selected results of a 2019–2020 multi-phase CHR workforce assessment. Specifically, we highlight CHR core roles and competencies, contributions to the social determinant of health and well-being and the level to which CHRs are integrated within systems and teams. We offer recommendations for strengthening the workforce, increasing awareness of CHR roles and competencies, integrating CHRs within teams and systems, and mechanism for sustainability.

Sleep Duration and Diabetes Risk in American Indian and Alaska Native Participants of a Lifestyle Intervention Project

STUDY OBJECTIVES

We examine the association between self-reported sleep duration and diabetes incidence in a national sample of American Indians/ Alaska Natives (AI/ANs) with prediabetes.

METHODS

Data were derived from the Special Diabetes Program for Indians Diabetes Prevention demonstration project. This longitudinal analysis included 1,899 participants with prediabetes recruited between January 1, 2006 and July 31, 2009 who reported sleep duration and completed all 16 classes of the lifestyle intervention consisting of diet, exercise, and behavior modification sessions to promote weight loss. Three years of follow-up data were included to fit Cox regression models to compute hazard ratios (HRs) for diabetes incidence across sleep duration categories.

RESULTS

The crude diabetes incidence rate was 4.6 per 100 person-years among short sleepers (≤ 6 h per night) compared to 3.2 among those sleeping 7 h and 3.3 among those sleeping 8 h or more. After adjustment for age and sex, short sleep (≤ 6 h vs. others) was associated with increased diabetes risk (HR 1.55 [95% confidence interval 1.11-2.17]); risk remained significantly elevated after controlling for socioeconomic characteristics, health behaviors, and health status. When adjusting for body mass index and percent weight loss, the short sleep-diabetes relationship was attenuated (HR 1.32 [95% confidence interval 0.92-1.89]). No significant long sleep-diabetes association was found. Further, short sleepers lost significantly less weight than others (3.7% vs. 4.3%, P = 0.003).

CONCLUSIONS

Short sleep duration, but not long duration, was significantly associated with increased diabetes risk and less weight loss among AI/ANs in a lifestyle intervention. Further exploration of the complex factors underlying short sleep duration is warranted.

Seasonality of suicide behavior in Northwest Alaska: 1990-2009

OBJECTIVES

Suicide is a leading cause of death worldwide, and disproportionately affects Indigenous populations. Seasonal suicide patterns are variable in the literature, and could offer novel approaches to the timing and focus of prevention efforts if better understood. With a suicide surveillance system in place since 1989, this study offers an unprecedented opportunity to explore seasonal variations in both fatal and non-fatal suicide behavior in an Indigenous Arctic region.

STUDY DESIGN

Cross-sectional.

METHODS

In this descriptive study, we analyzed data collected from 1990 to 2009 in the rural northwest region of Alaska, both graphically and using the chi-squared test for multinomials.

RESULTS

We found a significant monthly variation for suicide attempts, with a peak in suicide behavior observed between April and August (P = 0.0002). Monthly variation was more pronounced among individuals ≤29 years of age, and was present in both males and females, although the seasonal pattern differed by sex.

CONCLUSIONS

Our findings of a significant seasonal pattern in suicide behavior, with monthly variation (summer peak) in non-fatal suicide behavior among younger age groups, and among both males and females can assist planners in targeting subpopulations for prevention at different times of the year.

Problem-gambling severity and psychiatric disorders among American-Indian/Alaska native adults

INTRODUCTION

Little is known about the association between problem-gambling severity and psychiatric disorders among American-Indian/Alaska-Native (AI/AN) individuals. Thus, we examined these factors among a nationally representative sample of AI/AN and other American adults in the USA.

METHOD

Using the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) data, we conducted separate Wald tests and multinomial logistic regression analyses comparing AI/AN to black/African American, white/Caucasian, and all other racial/ethnic groups, respectively.

RESULTS

Relative to other American adults, AI/AN adults were least likely to report non-/low-frequency gambling (NG: AI/AN 66.5%, white/Caucasian 70.5%, black/African American 72.8%, other racial/ethnic group 72.3%) and most likely to report low-risk gambling (LRG: AI/AN 30.1%, white/Caucasian 26.5%, black/African American 23.4%, other racial/ethnic group 24.7%). The association between at-risk/problem-gambling (ARPG) and any past-year Axis-I disorder was stronger among AI/AN versus other American adults. Although ARPG and LRG were associated with multiple past-year Axis-I and lifetime Axis-II psychiatric disorders in both AI/AN and other American adults, LRG was more strongly associated with both Axis-I disorders (particularly major depression, generalized anxiety disorder and nicotine dependence) and Cluster-B Axis-II (particularly antisocial personality disorder) disorders in AI/AN versus other American adults.

DISCUSSION

A stronger association between problem-gambling severity and past-year psychiatric disorders among AI/AN relative to other American adults suggests the importance of enhancing mental health and problem-gambling prevention and treatment strategies that may help AI/AN individuals.