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To examine the impact of racial/ethnic coding strategies on the estimated prevalence of risk behaviors among American Indian/Alaska Native (AI/AN) high school students.Data from the national Youth Risk Behavior Survey (2017 and 2019) were analyzed (N=28,422). Racial/ethnic data were coded to identify "Multiracial/ethnic AI/AN students" and "AI/AN alone students." The prevalence of persistent feelings of sadness or hopelessness, suicidality, and violence victimization were compared across the coding schemes and with non-Hispanic White students.Of students who selfidentified as AI/AN, one in six (18%) were AI/AN alone. The prevalence of many health risk behaviors was significantly higher among AI/AN students than non-Hispanic/Latino White students. The precision of the risk behavior prevalence estimates, however, varied considerably.How racial/ethnic data were coded affected the precision of calculations of risk behavior prevalence among AI/AN students, who are often multiracial and of Hispanic/Latino ethnicity.

We used data from the Surveillance, Epidemiology, and End Results Program to examine trends in breast cancer treatment and survival among a large sample of American Indian and Alaska Native women diagnosed from 2000-2015. Kaplan-Meier and Cox proportional hazard models were used to estimate survival. Alaska Natives were more likely to undergo mastectomy (48% compared with 39% of American Indians and 36% of non-Hispanic Whites) and were less likely to receive breast reconstruction following mastectomy (9% compared with 17% of American Indians and 28% of non-Hispanic Whites). Alaska Natives had both lower overall (HR: 1.40 95% CI: 1.19-1.65) and breast-cancer specific (HR: 1.29, 95% CI: 1.03, 1.63) survival compared with non-Hispanic Whites. Survival differences across the three racial groups varied significantly by age. Efforts to improve survival among American Indian and Alaska Native populations will need to address barriers to access among these vulnerable populations.

Quitlines have great potential reach, utility, and effectiveness in promoting tobacco use cessation and for reducing tobacco-related health disparities (TRHDS). The existing literature underscores the particular promise of quitlines for addressing TRHDS among Black people and American Indians/Alaskan Natives. However, reach is a concern for several subgroups, including Latinx, sexual/gender minorities, and those with mental health conditions. The literature also suggests challenges regarding the efficacy of quitlines in promoting cessation among certain subgroups, such as low-income smokers or those with comorbid mental or physical health conditions. Strategies used to increase engagement and reach for subpopulations have included media campaigns and culturally-responsive communication strategies and intervention approaches. Further research is needed 1) to better document reach and effectiveness of quitlines for populations experiencing TRHDS; 2) to examine how best to adapt quitline approaches for specific populations with distinct needs; and 3) to examine scalable, low-cost strategies for increasing quitline reach and effectiveness and reducing TRHDS.

American Indians and Alaska Natives (AI/ANs) experience poor oral health. Children and adults living on the Navajo Nation have a particularly high rate of dental decay. The literature suggests that health outcomes are often associated with the strength of one’s ethnic identity. We investigated the association of ethnic identity among Native parents with oral health knowledge, attitudes, behavior, and outcomes. Analyses used baseline data from a randomized controlled trial designed to reduce dental decay among AI/AN preschoolers enrolled in the Navajo Nation Head Start Program. Greater perceived importance of ethnic identity was associated with better oral health knowledge and attitudes but was unassociated with oral health behavior and was linked to worse oral health status. Parents who were better able to speak their tribal language had greater confidence in their ability to manage their children’s oral health, engaged in better oral health behavior, and reported better parental oral health status.

The 2018-9 partial government shutdown created a 35-day gap in federal appropriations for the Indian Health Service and tribal health programs. With ongoing challenges for American Indian and Alaska Native health systems, including clinician shortages and poor health outcomes, the funding gap engendered substantial health risks. Other federal health systems have been sheltered from this and past shutdowns through receiving their appropriations in advance. Several approaches exist to implementing advance appropriations, including instituting advance appropriations across Bureau of Indian Affairs and Indian Health Service programs; or by moving Indian Health Service funding to the same appropriation as the Department of Health and Human Services. Furthermore, building and strengthening health partnerships with non-federal institutions, such as academic medical centers, may help distribute financial risk and strengthen care systems.

This study examines the extent to which data linkages between Indian Health Service, tribal data, and cancer registries affect cancer incidence rates among American Indians/Alaska Natives (AI/ANs) in Michigan. The incidence of tobacco- and alcohol-associated cancers for 1995-2012 was analyzed to compare rates of the Upper Peninsula (UP) and Lower Peninsula (LP) in Michigan and among AI/ANs and non-Hispanic Whites (NHWs). Complete linkage resulted in 1,352 additional AI/AN cases; 141 cases were linked via IHS records alone, while 373 were linked via tribal records alone; 838 were linked through both IHS and tribal records. Age-adjusted incidence rates for AI/ANs increased from 214.39 per 100,000 to 405.41 per 100,000, similar to that of NHWs after complete linkage (421.46 per 100,000). In the UP, AI/ANs had age-adjusted incidence rates 1.67 times higher than NHWs (596.69 per 100,000 vs. 356.32 per 100,000 respectively). This study indicates a substantial number of AI/AN cancer cases remain misclassified in Michigan.

Rural American Indian and Alaska Native (AI/AN) communities face physician vacancy rates over 25%. A variety of programs aim to address those gaps, from early-life STEM initiatives for AI/ANs to physician loan repayment programs. However, unfilled clinical positions and underrepresentation of AI/AN physicians persist. We review existing workforce initiatives, then demonstrate that three recently developed clinical fellowship programs fill an important gap. The fellowships, led by faculty at large academic health centers, place fellows in clinical positions in rural AI/AN communities in partnership with tribal health systems and/or the Indian Health Service. In addition to providing clinical care, the fellowships seek to enhance health systems' capacity development through community-centered initiatives that include training and health promotion. Other academic health centers should consider working together with tribal communities to assess whether replication of the models could reduce local physician staffing gaps and health disparities.

Compared with other racial/ethnic groups, American Indians and Alaska Natives (AIANs) have higher uninsured rates and worse health outcomes. Using data from the 2010-2014 American Community Survey, we employ logistic regression techniques to assess the characteristics associated with Indian Health Service (IHS) coverage among working-age AIANs who have health insurance or are uninsured. Across all insurance categories, geographic residence is a factor in IHS coverage. Among the uninsured, those with and without IHS coverage are more dissimilar than similar across socioeconomic characteristics. When controlling for confounding characteristics, people who are uninsured or have Medicaid have a much higher IHS coverage rate compared with those with employer-sponsored insurance. This indicates IHS coverage is an important component for the uninsured and it complements Medicaid services. This work identifies a need for increased outreach to eligible AIANs about IHS programs, particularly those without comprehensive care.

Binge drinking among American Indians and Alaskan Natives is an acute health issue in the United States. The Radcliffe Institute for Advanced Study at Harvard University convened a one-day meeting with North American experts to identify key elements for developing research methodologies to measure treatment outcomes founded in Indigenous cultural ways of knowing. Three were identified: recognize culture as treatment, overcome Western interpretations of research, and apply culturally appropriate research methodologies. Common across the elements is respectful relationship development, which mirrors the efforts of the Canadian Truth and Reconciliation Commission that was established to address the destructive legacy of residential schools among First Nations. Reconciling America's research response to binge drinking among American Indians and Alaskan Natives requires a similar commitment.

American Indians and Alaska Natives (AI/AN) experience significant health disparities relative to the general U.S. population. In particular, oral diseases affect the majority of the AI/AN population and their prevalence is significantly greater than observed in other demographic sectors of the U.S. population. The reasons for these disparities are multiple but lack of access to dental care is clearly a contributing factor. The dentist-to-population ratio in many AI/AN communities is less than half the U.S. average. A solution has been developed in Alaska by AI/AN leaders: dental therapists, i.e., local people trained for two years to provide basic dental services. This solution is being fought by organized dentistry that sees the approach as an economic threat, but AI/AN organizations are committed to implementing this Native solution to their access problem. The Alaska experience indicates that access to oral health services can be improved through the addition of dental therapists to the dental team.

Background. Health disparities between American Indians and Alaska Natives (AI/ANs) and non-Hispanic Whites (NHWs) may be partially explained in terms of health care access and utilization. Methods. We examined access to and utilization of health care for urban AI/ANs and NHWs in National Health Interview Survey data (2006–09). Results. Significant disparities exist for urban AI/ANs compared with urban NHWs. More AI/ANs are uninsured than NHWs, and more cited cost as the reason. More AI/ANs cannot afford needed medical care and more AI/ANs had not talked with a health care professional in the past year plus. Conclusions. Urban AI/ANs have decreased health care utilization and greater barriers to access compared with NHWs. Study data on the magnitude of disparity between urban AI/ANs and NHWs provides needed information to improve health care access and use in this population and can serve as a baseline for understanding the impact of health care reform.

Purpose. We aimed to determine whether the association between late-stage cancer and American Indian/Alaska Native (AI/AN) race differed by enrollment in the Indian Health Service Care System (IHSCS). Methods. We used Surveillance, Epidemiology, and End Results (SEER) data linked to Medicare files to compare the odds of late-stage breast, colorectal, lung, or prostate cancer between non-Hispanic Whites (NHWs) (n=285,993) and AI/ANs with (n=581) and without (n=543) IHSCS enrollment. Results. For AI/ANs without IHSCS enrollment, the odds of late-stage disease were higher in AI/ANs compared with NHWs for breast (OR=3.17, 95%CI: 1.82–5.53) and for prostate (OR=2.59, 95%CI:1.55–4.32) cancer, but not for colorectal or lung cancers. Among AI/ANs with IHSCS enrollment, there was not a significant association between late-stage disease and AI/AN race for any of the four cancers evaluated. Conclusion. Our results suggest that enrollment in the IHSCS reduced the disparity between AI/ANs and NHWs with respect to late-stage cancer diagnoses.

American Indian and Alaska Native (AI/AN) populations report poor physical and mental health outcomes while tribal health providers and the Indian Health Service (IHS) operate in a climate of significant under funding. Understanding how the Patient Protection and Affordable Care Act (ACA) affects Native American tribes and the IHS is critical to addressing the improvement of the overall access, quality, and cost of health care within AI/AN communities. This paper summarizes the ACA provisions that directly and/or indirectly affect the service delivery of health care provided by tribes and the IHS.

To assess whether timing of initial post-diagnosis cancer care differs between American Indian and Alaska Native (AI/AN) and non-Hispanic White (NHW) patients, we accessed SEER-Medicare data for breast, colorectal, lung, and prostate cancers (2001-2007). Medicare claims data were examined for initiation of cancer-directed treatment. Overall, AI/ANs experienced longer median times to starting treatment than NHWs (45 and 39 days, plt; .001) and lower rates of treatment initiation (HR[95%CI]: 0.86[0.79-0.93]). Differences were largest for prostate (HR: 0.80[0.71-0.89]) and smallest for breast cancer (HR: 0.96[0.83-1.11]). American Indians / Alaska Natives also had elevated odds of greater than 10 weeks between diagnosis and treatment compared with NHWs (OR[95% CI]: 1.37[1.16-1.63]), especially for prostate cancer (OR: 1.41[1.14-1.76]). Adjustment for comorbidity and socio-demographic factors attenuated associations except for prostate cancer. In this insured population, we observed evidence that AI/ANs start cancer therapy later than NHWs. The modest magnitude of delays suggests that they are unlikely to be a determinant of survival disparities.

Objective . To assess clinical treatment patterns and response times among American Indian/Alaska Native men with a newly elevated PSA. Methods . We retrospectively identified men ages 50–80 receiving care in one of three tribally-operated clinics in Northern Minnesota, one medical center in Alaska, and who had an incident PSA elevation ( 4 ng/ml) in a specified time period. A clinical response was considered timely if it was documented as occurring within 90 days of the incident PSA elevation. Results . Among 82 AI/AN men identified from medical records with an incident PSA elevation, 49 (60%) received a timely clinical response, while 18 (22%) had no documented clinical response. Conclusions . One in five AI/AN men in our study had no documented clinical action following an incident PSA elevation. Although a pilot study, these findings suggest the need to improve the documentation, notification, and care following an elevated PSA at clinics serving AI/AN men.

Introduction . Cancer is among the leading causes of death in American Indians and Alaska Natives (AI/ANs), with rates increasing over the last two decades. Barriers in accessing cancer screening and treatment likely contribute to this situation. Methods . We administered structured clinical interviews and conducted descriptive and multiple linear regression analyses of demographic, health, spiritual, and treatment factors associated with self-reported barriers to cancer care among 143 adult AI/AN oncology patients. Results . High levels of satisfaction with cancer care, older age, positive mental health quality of life, and positive physical health quality of life were all significantly associated with lower scores for cancer care barriers, explaining 27% of the total model variance. Conclusion . Addressing barriers to cancer care might help to reduce health disparities among AI/AN oncology patients. Future research should determine whether reducing barriers improves engagement with cancer treatment and overall health outcomes.

American Indian/Alaska Native (AI/AN) children have a high risk for poor health outcomes. Race/ethnicity and functional impairments are linked with health care disparities. While data exist for other race/ethnicity groups, little is known about outcomes for AI/AN children with functional impairments. In this study the Functional Independence Measure for Children (WeeFIM®) was used to determine differences in outcomes between AI/AN and White children receiving inpatient rehabilitation for functional impairments at one pediatric rehabilitation facility. American Indian/Alaska Native and White children had similar impairment types and functional levels at admission to inpatient rehabilitation. Both groups experienced functional improvement during rehabilitation. At discharge, AI/AN children had lower total functional scores and had less improvement in mobility scores compared with White children, with more impairment in physical mobility at discharge. This is one of the first studies to show a disparity in functional outcomes for AI/AN children compared with White children during inpatient rehabilitation.

Introduction . We investigated incidence and staging patterns of prostate, female breast, lung, and colorectal cancer among American Indians/Alaska Natives (AI/ANs) and non-Hispanic Whites (NHWs) in the Northern Plains. Methods . Cancer registry data (2002–2009) from Nebraska, North Dakota, and South Dakota were analyzed. Incidence rates were calculated and multivariate logistic regression analyses identified factors associated with unstaged versus staged and late-stage cancer cases versus early. Results . The incidence rate was higher among AI/ANs than NHWs for lung cancer (92.2 vs. 60.6 per 100,000). Compared with NHWs, AI/ANs were 2.0 times more likely to receive an unstaged diagnosis and 1.2 times more likely to receive a late-stage diagnosis. AI/ANs were significantly more likely than NHWs to receive an unstaged diagnosis. Discussion . Increased efforts are needed to reduce unstaged and late-stage diagnoses among Northern Plains AIs. Efforts to promote early detection of cancer should target younger AI/ANs.