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Research on misperceived descriptive and injunctive drinking norms, or normative perceptions of frequency, quantity, and acceptability of drinking, has rarely been extended to American Indian/Alaska Native (AI/AN) college student populations. Ethnic identity, or strength of one's ties to their AI/AN culture, has been hypothesized as a protective factor against problematic alcohol use. As a step toward informing culturally appropriate and gender-specific norms-based interventions for AI/AN students, this study examined differences between perceived and actual descriptive and injunctive drinking norm reference groups (e.g., AI/AN males/females, "typical" males/females), and investigated ethnic identity as a moderator between perceived and actual drinking norms.AI/AN college students (Compared to actual drinking levels, participants overestimated all gender-specific descriptive norm groups and all gender-specific injunctive norm groups except for AI/AN males. Participants estimated lower drinking levels for AI/AN-specific groups than non-AI/AN groups. Descriptive AI/AN male and best male friend norms significantly predicted drinking for men while only best female friend norms predicted drinking for women. Injunctive typical male norms significantly predicted drinking for men, and no injunctive norms predicted drinking for women. Finally, ethnic identity was unrelated to drinking and did not significantly moderate the relation between perceived and actual drinking.Current findings may inform norms-based alcohol use interventions, as AI/AN-specific reference groups may have a significant impact on drinking among men, but not women. Future culturally relevant alcohol use intervention research for AI/AN young adults is warranted. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Indigenous knowledge and practices promote American Indian/Alaska Native (AI/AN; Native) communities' health and well-being. Historical losses and continued oppression have resulted in disproportionately higher AI/AN youth suicide rates. This article describes the development of a new national resource guide titled "CULTURE FORWARD" for tribal leaders and stakeholders to support youth suicide prevention efforts through cultural strengths.The CULTURE FORWARD guide was developed over 6 months through a community-engaged process. We conducted nine roundtables and eight interviews with a wide variety of community members, leaders, and providers representing 36 diverse tribal communities and geographic regions. Participants discussed AI/AN youth risk and protective factors, successful community efforts to prevent suicide, and content and dissemination ideas. A comprehensive literature review complemented qualitative findings. A diverse and representative National Advisory Editorial Board guided content and design throughout development.Qualitative data were analyzed iteratively and thematically. Across all listening sessions, culture was identified as a key protective factor against AI/AN youth suicide. Five themes related to cultural strengths informed guide chapters. Each chapter includes an introduction; how that theme helps prevent Native youth suicide; a review of academic literature, community stories and programs; action steps; and additional resources.CULTURE FORWARD honors and empowers communities by weaving strands of knowledge, stories, and practical resources highlighting Native communities' strengths to protect against Native youth suicide. The guide is free online and print copies are being distributed nationally. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Objectives. To evaluate COVID-19 disparities among non-Hispanic American Indian/Alaska Native (AI/AN) and non-Hispanic White persons in urban areas. Methods. Using COVID-19 case surveillance data, we calculated cumulative incidence rates and risk ratios (RRs) among non-Hispanic AI/AN and non-Hispanic White persons living in select urban counties in the United States by age and sex during January 22, 2020, to October 19, 2021. We separated cases into prevaccine (January 22, 2020–April 4, 2021) and postvaccine (April 5, 2021–October 19, 2021) periods. Results. Overall in urban areas, the COVID-19 age-adjusted rate among non-Hispanic AI/AN persons (n = 47 431) was 1.66 (95% confidence interval [CI] = 1.36, 2.01) times that of non-Hispanic White persons (n = 2 301 911). The COVID-19 prevaccine age-adjusted rate was higher (8227 per 100 000; 95% CI = 6283, 10 770) than was the postvaccine rate (3703 per 100 000; 95% CI = 3235, 4240) among non-Hispanic AI/AN compared with among non-Hispanic White persons (2819 per 100 000; 95% CI = 2527, 3144; RR = 1.31; 95% CI = 1.17, 1.48). Conclusions. This study highlights disparities in COVID-19 between non-Hispanic AI/AN and non-Hispanic White persons in urban areas. These findings suggest that COVID-19 vaccination and other public health efforts among urban AI/AN communities can reduce COVID-19 disparities in urban AI/AN populations. (Am J Public Health. 2022;112(10):1489–1497. https://doi.org/10.2105/AJPH.2022.306966 )

Food insecurity, defined as insufficient access to nutritious foods, is a social determinant of health that may underpin health disparities in the US. American Indian and Alaska Native (AI/AN) individuals experience many health inequities that may be related to food insecurity, but no systematic analyses of the existing evidence have been published. Thus, the objective of this scoping review was to assess the literature on food insecurity among AI/AN individuals and communities, with a focus on the prevalence of food insecurity and its relations to sociodemographic, nutrition, and health characteristics. Systematic search and data extraction processes were used. Searches were conducted on PubMed as well as peer-reviewed journal and government websites. Of 3174 identified references, 34 publications describing 30 studies with predominantly AI/AN sample populations were included in the final narrative synthesis. Twenty-two studies (73%) were cross-sectional and the remaining 8 (27%) described interventions. The weighted average prevalence of food insecurity across the studies was 45.7%, although estimates varied from 16% to 80%. Most studies used some version of the USDA Food Security Survey Modules, although evidence supporting its validity in AI/AN respondents is limited. Based on the review, recommendations for future research were derived, which include fundamental validity testing, better representation of AI/AN individuals in federal or local food security reports, and consideration of cultural contexts when selecting methodological approaches. Advances in AI/AN food insecurity research could yield tangible benefits to ongoing initiatives aimed at increasing access to traditional foods, improving food environments on reservations and homelands, and supporting food sovereignty.

The Winnipeg Boldness Project, a social innovation initiative addressing early childhood outcomes in the underserved community of Point Douglas, worked alongside the community to develop a meaningful measurement tool, the North End Wellbeing Measure (NEWM). This article describes the context, the research and pilot, and the lessons learned.To develop a community-based tool called the NEWM, which evaluates what is important to Point Douglas families.We used community-based participatory research methods and surveys for data collection.We learned that 1) the language used in relation to notions of well-being and satisfaction could be more precise, 2) our assumptions about strengths-based measurement did not always align with community perspectives, 3) hiring Indigenous people as data collectors is essential, and 4) we need to remain vigilant in our attention to respecting the participants' lived experiences. We also learned that, given the opportunity, the community has a desire to participate in research involving their experiences and well-being and greatly benefit from self-voicing and agency in research development.The pilot NEWM demonstrates the benefits and challenges of Indigenous social innovation and will benefit future iterations of the measure, as well as other community-based well-being measures.

Family Spirit (FS) is a federally endorsed evidence-based home visiting programs serving as a key prevention strategy for expectant families and families with young children. Like other home-visiting programs, it shares client challenges in retention and engagement during implementation. We assessed (1) the feasibility and acceptability of implementing a precision approach to FS; and (2) differences in approaches to FS delivery. Home visitors, serving primarily Native American families, that delivered a standard (N = 6) or a precision approach (N = 6) to FS across four study sites each participated in up to four virtual focus group discussions (FGDs) (N = 16). Facilitators and barriers to implementation were identified across the curriculum approach, relational and contextual levels. Facilitators: Relevant and culturally sensitive lessons, lesson structure, client-home visitor relationship, client buy-in, home visitor autonomy, leadership support, flexible funding, and training. Barriers: Irrelevant lessons, substance use content, missing topics, families experiencing crises, client and home visitor availability, client feedback, nonsupportive leadership, inadequate funding, and organizational policies and practices. The precision approach offers (1) tailoring of lessons that supports relevance of content to clients; and (2) a target timeframe that supports flexibility in lesson delivery. This model structure may improve client participation and retention.Espíritu de Familia (FS) es un programa de visitas a casa con base en la evidencia y respaldado federalmente, el cual sirve como una estrategia clave de prevención para familias con niños pequeños que esperan otro niño. Tal como otros programas de visitas a casa, éste comparte los retos de los participantes en cuanto a retención y participación activa durante la implementación. Evaluamos 1) la factibilidad y accesibilidad de implementar un acercamiento de precisión a FS; y 2) las diferencias en cuanto al acercamiento del ofrecimiento de FS. Los visitadores a casa, quienes primariamente les sirven a familia nativo-americanas, y que ofrecieron un acercamiento estándar (N = 6) o uno de precisión (N = 6) a FS a través de 4 lugares de estudio, cada uno participó en un máximo de 4 discusiones virtuales de grupos de enfoque (N = 16). Los aspectos que facilitaron y las barreras a la implementación se identificaron a lo largo de los niveles de acercamiento, relacionales y contextuales del currículo. Aspectos que facilitaron: lecciones relevantes y culturalmente sensibles, estructura de lecciones, la relación entre el participante-casa y el visitador, la aceptación por parte del participante, la autonomía del visitador a casa, el apoyo de liderazgo, la flexibilidad de los fondos, así como el entrenamiento. Barreras: lecciones irrelevantes, contenido sobre uso de sustancias, temas que no se incluyeron, las familias que experimentaban una crisis, la disponibilidad del participante y del visitador, información aportada por el participante, falta de apoyo del liderazgo, fondos inadecuados, así como las políticas y prácticas organizacionales. El acercamiento de precisión ofrece 1) moldear las lecciones que apoyan la relevancia del contenido a los participantes; y 2) un definido marco de tiempo que apoya la flexibilidad del ofrecimiento de las lecciones. Esta estructura de modelo pudiera mejorar la participación y retención de participantes.Le programme Family Spirit (FS, soit Esprit de Famille) est une programme américain, basé sur des données probantes, avalisé par le gouvernement américain, de visite à domicile, servant de stratégie de prévention clé pour les familles attendant un enfant ou les familles avec de jeunes enfants. Comme d'autres programmes de visite à domicile, ce programme partage des difficultés dans la rétention et l'engagement des clients durant la mise en oeuvre. Nous avons évalué 1) la fiabilité et l'acceptabilité de la mise en œuvre d'une approche de précision du FS; et 2) des différences dans les approches de l'application du FS. Les visiteurs à domicile, servant principalement des familles amérindiennes américaines, qui ont présenté une approche standard (N = 6) ou une approche de précision (N = 6) du FS et au travers de 4 sites d’étude chacun ont participé à jusqu’à 4 discussions de groupe d’étude virtuels (n = 16). Les aspects facilitateurs et les barrières à la mise en place ont été identifiés au travers de l'approche du curriculum, des niveaux relationnels et contextuels. Aspects de facilitation: leçons pertinentes et culturellement sensibles, structure de la leçon, relation client-visiteur à domicile, adhésion du client, autonomie du visiteur à domicile, soutient des dirigeants, budget flexible, formation. Barrières: leçons n’étant pas pertinentes, contenu d'usage de substance, sujets qui manquent, familles faisant l'expérience de crises, disponibilité du client et du visiteur à domicile, retour du client, dirigeants qui n'offrent aucun soutien, budget inadéquat, et politiques et pratiques organisationnelles. L'approche de précision offre 1) une adaptation sur mesure des leçons qui soutient la pertinence du contenu pour les clients; et 2) un délai ciblé qui soutient la flexibilité de l'enseignement. Cette structure de modèle peut améliorer la participation et la rétention.Praxisperspektiven auf die Implementierung eines Präzisionskonzepts für Hausbesuche bei Familien in Gemeinden amerikanischer Ureinwohner:innen “Family Spirit” (FS) ist ein staatlich anerkanntes, evidenzbasiertes Hausbesuchsprogramm, das eine wichtige Präventionsstrategie für werdende Familien und Familien mit kleinen Kindern darstellt. Wie andere Hausbesuchsprogramme hat auch dieses Programm während der Implementierung mit Herausforderungen wie mangelndes Engagement und fehlende Verbindlichkeit der Klient:innen zu kämpfen. Wir untersuchten 1) die Durchführbarkeit und Akzeptanz der Implementierung eines präzisen FS-Ansatzes und 2) die Unterschiede in den verschiedenen Ansätzen zur Durchführung von FS. Hausbesuchende, die vor allem Familien amerikanischer Ureinwohner:innen betreuen, nahmen an bis zu vier virtuellen Fokusgruppendiskussionen (N = 16) teil, die entweder einen Standard- (N = 6) oder einen Präzisionsansatz (N = 6) für FS an vier Studienstandorten verfolgten. Erleichterungen und Hindernisse für die Umsetzung wurden auf den Ebenen des Lehrplanansatzes, der Beziehungen und des Kontextes ermittelt. Erleichternde Faktoren: Relevante und kultursensible Lektionen, Struktur innerhalb der Lektion, Beziehung zwischen Klient:innen und Hausbesuchenden, Zustimmung der Klient:innen, Autonomie der Hausbesuchenden, Unterstützung durch die Leitung, flexible Finanzierung und Schulung. Hindernisse: Irrelevante Lektionen, Inhalte zum Substanzkonsum, fehlende Themen, Familien in Krisensituationen, Verfügbarkeit von Klient:innen und Hausbesuchenden, Klient:innenfeedback, nicht unterstützende Führung, unzureichende Finanzierung und organisatorische Richtlinien und Praktiken. Der Präzisionsansatz bietet 1) maßgeschneiderte Lektionen, die die Relevanz der Inhalte für die Klient:innen unterstützen, und 2) einen Zielzeitrahmen, der die Flexibilität bei der Durchführung der Lektionen unterstützt. Diese Modellstruktur kann die Teilnahme und Bindung der Klient:innen verbessern.アメリカ先住民の家族を対象としたコミュニティにおける家庭訪問の高精度アプローチの実施に関する家庭訪問員の視点 ファミリー・スピリット (FS) は、連邦政府によって承認されたエビデンスに基づく家庭訪問プログラムで、妊産婦と乳幼児のいる家庭のための重要な予防戦略として機能している。FSには他の家庭訪問プログラムと同様の、実施中のクライアントの定着と参加に関する課題がある。我々は、1) アプローチによる家庭訪問の実施可能性と受容性 、2) 家庭訪問の実施方法の違い、について評価した。4つの研究施設で、主にネイティブアメリカンの家族を対象に、標準的なアプローチ (N = 6) または高精度アプローチ (N = 6) のFSを実施する家庭訪問員が、それぞれ最大4回のオンラインでのフォーカス・グループ・ディスカッションに参加した (N = 16) 。カリキュラムのアプローチ、関係性、文脈の各レベルにおいて、実施の促進要因と障壁となる要因が特定された。促進要因:文化的に配慮した適切な講習 、講習の構成、クライアントと家庭訪問員の関係、クライアントの賛同、家庭訪問員の自主性、指導者のサポート、柔軟な資金調達、研修。障壁要因:クライエントに関連性のない講習、薬物使用の内容、必要なトピックが不足していたこと 、危機を経験した家族、クライアントと家庭訪問員の対応可能性、クライアントのフィードバック、非支持的なリーダーシップ、不十分な資金、組織の方針と実践。高精度アプローチは1) クライアントに関連性のある講習のオーダーメイド化を実現し、2) 目標時間枠を設定することで、柔軟にレッスンを提供することができる。このモデル構造は、クライアントの参加率と定着率を向上させる可能性がある。.“家庭精神” (FS) 是一项联邦政府认可的循证家访计划, 是有孕妇家庭和有幼儿家庭的关键预防策略。与其他家访计划一样, 它在实施过程中也面临着客户留存和参与方面的挑战。我们评估了 1) 采取精准方法实施FS的可行性和可接受性; 2) FS实施方法的差异。家访者主要为美国原住民家庭提供服务, 他们在4个研究地点采取标准 (N = 6) 或精准方法 (N = 6) 实施FS, 每个人参加最多4次虚拟焦点小组访谈 (N = 16) 。在课程方法、关系和背景层面上确定了实施的促进因素和障碍因素。促进因素:相关的和文化敏感的课程、课程结构、客户与家访者关系、客户支持、家访者自主权、领导支持、灵活的资金和培训。障碍因素:无关的课程、药物使用内容、遗漏的话题、经历危机的家庭、客户与家访者的可用性、客户反馈、非支持性领导、资金不足以及组织政策和实践。精准方法提供 1) 内容与客户相关性的课程定制; 2) 灵活授课的目标时间表。这种模型结构可以提高客户参与度和留存率。.وجهات نظر زوار المنزل حول تنفيذ نهج دقيق لزيارة المنزل في المجتمعات التي تخدم العائلات الأمريكية الأصلية يمثل Family Spirit أو (FS) مجموعة برامج زيارة منزلية قائمة على الأدلة ومعتمدة فيدراليًا وتعمل كاستراتيجية وقائية رئيسية للعائلات المنتظرة والعائلات التي لديها أطفال صغار. وقد قمنا بتقييم 1) جدوى ومقبولية تنفيذ نهج دقيق في برامج FS ؛ و 2) الاختلافات في مناهج تقديم برامج FS. شارك زوّار المنزل ، الذين يخدمون في المقام الأول عائلات أمريكية أصلية ، في الدراسة حيث شارك كل من الذين قدموا النهج التقليدي(N = 6) أو النهج الدقيق(N = 6) عبر 4 مواقع دراسة ، و 4 مناقشات لمجموعة تركيز افتراضية (N = 16). تم تحديد العوامل الميسرة والمعوقات في التنفيذ عبر المنهج الدراسي والمستويات العلائقية والسياقية. العوامل الميسرة: الدروس ذات الصلة والحساسة ثقافيًا ، وهيكل الدرس ، والعلاقة بين العميل والمنزل ، واشتراك العميل ، واستقلالية زائر المنزل ، ودعم القيادة ، والتمويل المرن ، والتدريب. العوائق: الدروس غير ذات الصلة ، محتوى تعاطي المخدرات ، الموضوعات المفقودة ، العائلات التي تعاني من الأزمات ، توفر العميل وزائر المنزل ، ملاحظات العملاء ، القيادة غير الداعمة ، التمويل غير الكافي ، والسياسات والممارسات التنظيمية. يقدم نهج الدقة 1) تكييف الدروس التي تدعم ملاءمة المحتوى للعملاء ؛ و 2) إطار زمني مستهدف يدعم المرونة في تقديم الدروس. قد يحسن هيكل هذا النموذج مشاركة العملاء والاحتفاظ بهم.

While implementation and dissemination of research is a rapidly growing area, critical questions remain about how, why, and under what conditions everyday people integrate and utilize research evidence. This mixed-methods study investigates how participants of Promoting Community Conversations About Research to End Suicide (PC CARES) make sense of and use research evidence about suicide prevention in their own lives. PC CARES is a health intervention addressing the need for culturally responsive suicide prevention practices in rural Alaska through a series of community Learning Circles. We analyzed PC CARES transcripts and surveys for 376 participants aged 15+ across 10 Northwest Alaska Native villages. Quantitative analysis showed significant correlations between five utilization of research evidence (URE) factors and participants' intent to use research evidence from PC CARES Learning Circles. Key qualitative themes from Learning Circle transcripts expanded upon these URE constructs and included navigating discordant information, centering relationships, and Indigenous worldviews as key to interpreting research evidence. We integrate and organize our findings to inform two domains from the Consolidated Framework for Research Implementation: (1) intervention characteristics and (2) characteristics of individuals, with emphasis on findings most relevant for community settings where self-determined, evidence-informed action is especially important for addressing health inequities.

As with many Indigenous populations globally, American Indians and Alaska Natives (AI/ANs) experience high rates of type 2 diabetes. Prevention efforts, ongoing medical care, patient self-management education, and support to prevent and reduce the risk of long-term complications must be developed to limit the impact of diabetes on individuals, families, and communities. Diabetes prevention and control require both individual- and community-level efforts as well as policies that attempt to mitigate contributing adverse socioeconomic factors. Congressional funding since 1998 continues to address the epidemic of diabetes in AI/AN groups with the Special Diabetes Program for Indians (SDPI), which has resulted in significant outcomes and key lessons that can inform new efforts to prevent diabetes in other populations and communities. The purpose of this review is to understand the context behind the epidemic of diabetes in AI/ANs, review the impact of the SDPI on prevention and control of diabetes as well as the translation of these strategies into clinical practice and their influence on health practice, and identify lessons learned for future efforts to address this ongoing challenge for AI/AN and other communities suffering from type 2 diabetes.

American Indians and Alaska Natives (AIANs) face significant health disparities that are exacerbated by limited access to high-quality, culturally congruent health care providers. There are no premedical postbaccalaureate programs focused on AIAN students.The Northwest Native American Center of Excellence designed the Wy'east Pathway in 2018 to increase the number of AIANs matriculating to U.S. medical schools by supporting those on the cusp of matriculation. Wy'east scholars undertake 10 months of structured programming to augment their academic preparation, improve their Medical College Admission Test (MCAT) scores, and enhance their confidence and cultural identity. Cultural events and mentorship opportunities with AIAN faculty, staff, and cultural liaisons are threaded throughout the pathway curriculum to foster cultural resilience, mentorship, and community. Scholars earn conditional acceptance to Oregon Health and Science University (OHSU) School of Medicine if they complete Wy'east and meet the following criteria: pass all examinations in the primary curricular threads, obtain a qualifying MCAT score, and meet professionalism standards.All 14 scholars who successfully completed Wy'east and met criteria in the first 2 cohorts (academic years 2018-2019 and 2019-2020) earned conditional acceptance to OHSU School of Medicine. Ten of the 14 scholars (71.4%) matriculated to OHSU School of Medicine, 2 (14.3%) matriculated to other medical schools, and 2 (14.3%) chose to pursue other health care fields. Wy'east scholars rated the foundational science of medicine and population health and epidemiology threads higher in terms of making them feel better prepared for medical school (mean = 4.71 and 4.83, respectively) than the academic skills and wellness thread (mean = 3.43).Over the next 5 years, Wy'east will grow incrementally to offer a total of 18 conditional acceptance spots per cohort across 3 medical schools. Longitudinal tracking of Wy'east scholars' medical training and career outcomes will be conducted.

The American Indian/Alaska Native (AI/AN) suicide rate in Alaska is twice the state rate and four times the U.S. rate. Healthcare systems need innovative methods of suicide risk detection. The Mental Health Research Network (MHRN) developed suicide risk prediction algorithms in a general U.S.We applied MHRN predictors and regression coefficients to electronic health records of AI/AN patients aged ≥13 years with behavioral health diagnoses and primary care visits between October 1, 2016, and March 30, 2018. Logistic regression assessed model accuracy for predicting and stratifying risk for suicide attempt within 90 days after a visit. We compared expected to observed risk and assessed model performance characteristics.10,864 patients made 47,413 primary care visits. Suicide attempt occurred after 589 (1.2%) visits. Visits in the top 5% of predicted risk accounted for 40% of actual attempts. Among visits in the top 0.5% of predicted risk, 25.1% were followed by suicide attempt. The best fitting model had an AUC of 0.826 (95% CI: 0.809-0.843).The MHRN model accurately predicted suicide attempts among AI/AN patients. Future work should develop clinical and operational guidance for effective implementation of the model with this population.

American Indian and Alaska Native (AI/AN) persons bear a disproportionate burden of human papillomavirus (HPV)-associated cancers and face unique challenges to HPV vaccination. We undertook a systematic review to synthesize the available evidence on HPV vaccination barriers and factors among AI/AN persons in the United States. We searched fourteen bibliographic databases, four citation indexes, and six gray literature sources from July 2006 to January 2021. We did not restrict our search by study design, setting, or publication type. Two reviewers independently screened the titles and abstracts (stage 1) and full-text (stage 2) of studies for selection. Both reviewers then independently extracted data using a data extraction form and undertook quality appraisal and bias assessment using the modified Mixed Methods Appraisal Tool. We conducted thematic synthesis to generate descriptive themes. We included a total of 15 records after identifying 3017, screening 1415, retrieving 203, and assessing 41 records. A total of 21 unique barriers to HPV vaccination were reported across 15 themes at the individual (n = 12) and clinic or provider (n = 3) levels. At the individual level, the most common barriers to vaccination-safety and lack of knowledge about the HPV vaccine-were each reported in the highest number of studies (n = 9; 60%). The findings from this review signal the need to develop interventions that target AI/AN populations to increase the adoption and coverage of HPV vaccination. Failure to do so may widen disparities.

Culturally grounded after-school programs (ASPs), based on local cultural values and practices, are often developed and implemented by and for the local community. Culturally grounded programs promote health and well-being for American Indian and Alaska Native (AI/AN) adolescents by allowing them to reconnect to cultural teachings that have faced attempted historical and contemporary erasure. This article is a first-person account that describes the development and implementation of a culturally grounded ASP, Native Spirit (NS), for AI adolescents (grades 7-12) living on a Southwest urban-based reservation. NS, a 13-session culturally grounded ASP, was developed by an academic-community partnership that focuses on increasing cultural engagement as a form of positive youth development. Each session was guided by one to two local cultural practitioners and community leaders. The development of the NS program contributed to an Indigenous prevention science that emphasizes the positive impacts of Indigenous culture and community on health and well-being. The use of the ASP format, in partnership with the BoysGirls Club, increased the feasibility of dissemination and refinement of the NS program by tribal communities and organizations.

PURPOSE OF REVIEW: The latest national data reports a 55% prevalence of metabolic syndrome in American Indian adults compared to 34.7% of the general US adult population. Metabolic syndrome is a strong predictor for diabetes, which is the leading cause of heart disease in American Indian and Alaska Native populations. Metabolic syndrome and associated risk factors disproportionately impacts this population. We describe the presentation, etiology, and roles of structural racism and social determinants of health on metabolic syndrome. FINDINGS: Much of what is known about metabolic syndrome in American Indian and Alaska Native populations comes from the Strong Heart Study as there is scant literature. American Indian and Alaska Native adults have an increased propensity towards metabolic syndrome as they are 1.1 times more likely to have high blood pressure, approximately three times more likely to have diabetes, and have higher rates of obesity compared with their non-Hispanic White counterparts. Culturally informed lifestyle and behavior interventions are promising approaches to address structural racism and social determinants of health that highly influence factors contributing to these rates. SUMMARY: Among American Indian and Alaska Native populations, there is scarce updated literature evaluating the underlying causes of major risk factors for metabolic syndrome, and progression to cardiometabolic disease. As a result, the actual state of metabolic syndrome in this population is not well understood. Systemic and structural changes must occur to address the root causes of these disparities.

1) To detail how racism and its intersection with the social determinants of health affect the oral health of Blacks or African Americans (B/AA), Hispanics or LatinX (H/L), and American Indians and Alaska Natives (AI/AN) as well as their ability to thrive and succeed in dental academic and professional settings; 2) to describe how the Diverse Dental Society is addressing the oral health of these ethnic/racial populations METHODS: The processes in which 1) structural (systemic) and cultural racism operate in the living and working environments of B/AA, H//L, and AI/AN to impact oral health outcomes and 2) B/AA, HL, and AI/AN oral health organizational leaders are collectively addressing the oral health effects of racism are examined RESULTS: Structural racism and cultural racism and their intersection with the social determinants of health adversely affect the oral health of B/AA, H/L, and AI/AN as well as their ability to thrive and succeed in dental academic and professional settings.The leaders of the Hispanic Dental Association, National Dental Association, and the Society of American Indian Dentists realize that it will take collective action under the auspices of the Diverse Dental Society to synergize their organizations' individual efforts to create systemic change to address racial and health inequities and improve oral health outcomes.

Background. Hepatitis C virus (HCV) infection incidence rates in the United States have increased since 2010 as a byproduct of the opioid crisis despite the introduction of direct-acting antiviral agents in 2013. HCV infection is associated with higher rates of liver-related and nonhepatic causes of death. Methods. This study compared demographic characteristics and age-adjusted death rates from 1995 to 2016 among Alaska Native (AN) adults infected with HCV (AK-HepC) to rates among the AN and non-AN adult populations living in Alaska. Liver-related disease (LRD) and other disease-specific age-adjusted death rates were compared between the populations. Results. The all-cause death rate among the AK-HepC cohort was 2.2- and 3.4-fold higher than AN and non-AN adults, respectively, and remained stable over time in all populations. The LRD death rate among the AK-HepC cohort was 18- and 11-fold higher than the non-AN and AN, respectively. The liver cancer rate among the AK-HepC cohort was 26-fold higher compared to the Alaska statewide population. The AK-HepC cohort had elevated rates of death associated with nonhepatic diseases with circulatory disease having the highest rate in all populations. Among liver cancer deaths in the AK-HepC cohort, 32% had HCV listed as a contributing cause of death on the death certificate. Conclusions. Death rates in the AK-HepC cohort remained stable since 1995 and higher compared to the general population. People with HCV infection had an elevated risk for all-cause, liver-related, and nonhepatic causes of death. Hepatitis C infection may be underrepresented as a cause of mortality in the United States.

OBJECTIVE: To explore the perspectives of urban-dwelling American Indian and Alaska Native (AI/AN) older adults regarding determinants of healthy eating, food insecurity, and opportunities for an urban clinic to improve resources. METHODS: Semistructured interviews (n = 24) with older adults (aged ≥ 60 years) at 1 urban AI/AN serving clinic. Telephone-based interviews were audio-recorded, professionally transcribed, and analyzed using thematic analysis. RESULTS: Four overarching themes were revealed: (1) hunger-mitigating resources exist but do not necessarily lessen food insecurity; (2) multiple layers of challenges related to social determinants of health present barriers to healthy nutrition for AI/AN older adults; (3) unique facilitators rooted in AI/AN culture can help decrease food insecurity; and (4) many clinic-based opportunities for programs to improve food insecurity exist. CONCLUSIONS AND IMPLICATIONS: Findings provide a foundation for urban-serving AI/AN clinics to develop healthy eating resources for their older adult patients. Greater benefit would result from resources that build on cultural strengths and address older adult-specific challenges to healthy eating.

In 2019, 5 cases of invasive Haemophilus influenzae serotype b (Hib) occurred in the Anchorage region of Alaska over a period of 16 days. No cases had occurred in Alaska in the preceding 26 months.Alaska Hib isolates from 2005 through 2019 were analyzed using whole-genome sequencing (WGS). Rates were compared with the CDC's Active Bacterial Core surveillance (ABCs) data.A total of 33 cases of invasive Hib occurred in Alaska from 2005 through 2019. Of the 5 cases associated with the cluster, 2 (40%) occurred in adults and all occurred in the Anchorage region. In contrast, only 14% (4/28) of the noncluster cases occurred in this region (P0.01). Two cluster cases were linked epidemiologically and the bacteria were nearly identical. The other 3 cluster cases were caused by 3 genetically distinct bacteria. When the full period was evaluated, the unadjusted rate of invasive Hib disease in Alaska was 15.5 times higher in Alaska Native (AN) people than non-AN people [1.3/100,000 vs. 0.07/100,000, 95% confidence intervals (CI): 10.2-22.5). The age-adjusted rate of invasive Hib disease in Alaska was 9.4 times higher than the ABCs rate (95% CI: 6.3-14.1).While clustered in time and space, the 5 cases in 2019 were not due to a single bacterial strain. AN people continue to have elevated rates of invasive Hib infection compared with both non-AN people in Alaska and the ABCs population.

Like other areas of health, structural racism has a deep impact on oral health and is a key driver of racial inequities in access to care and outcomes. Racism also structures the relationship between oral health and access to economic opportunities. As a result, communities of color, American Indian/Alaska Native (AI/AN) communities, and low-income populations experience the highest rates of the health, social, and economic costs of dental disease. This is compounded by issues of community-level dental fear/trauma resulting from receiving itinerate care. Dentistry has long struggled to equitably distribute care and diversify its overwhelmingly white and affluent workforce, resulting in many communities not having access to providers who represent their identity and/or live in their community. While multi-generational lack of access to dental care is not unique to Alaska, Alaska Native communities are the home to a reimagined, community-centered care delivery system that is improving health outcomes. For almost two decades, AI/AN leaders have recruited and trained community members to serve as dental therapists-dental team members who offer routine and preventive care responsive to local geographic and cultural/community norms. As members of the communities they serve, dental therapists are fluent in the language and cultural norms of their patients, improving patient-provider trust, access to care, and oral health outcomes. The communities that dental therapists serve are also now investing money and training in their community members, building educational opportunities, and professional wage jobs and directly countering the economic impact structural racism has on oral health.

BACKGROUND: COVID-19 has profoundly affected sleep, although little research has focused on high-risk populations for poor sleep health, including American Indian/ Alaska Native (AI/AN) adolescents. METHODS: This is the first longitudinal study to examine changes in sleep with surveys completed before the pandemic and during the early months of COVID-19 in a sample of urban AI/AN adolescents (N=118; mean age= 14 years at baseline; 63% female). We use a mixed-methods approach to explore how COVID-19 affected urban AI/AN adolescents’ sleep, daily routines, and interactions with family and culture. Quantitative analysis examined whether pandemic-related sleep changes were significant and potential moderators of COVID-19’s effect on sleep, including family and community cohesion and engagement in traditional practices. RESULTS: Findings demonstrate changes in sleep, including increases in sleep duration, delays in bedtimes and waketimes, and increases in sleep-wake disturbances (p’s

Community-based participatory research is a particularly powerful approach to research with American Indian and Alaska Native (AIAN) communities who have been subject to a history of mistreatment and unethical research. In person meetings, discussion, and engagement with tribal members and the community have become an essential component of community-based participatory research in AIAN communities. With the advent of the coronavirus disease 2019 pandemic, AIAN communities have moved to close or sharply curtail in-person activities, precluding in-person research methods. Current best practices for research with AIAN communities assumes in-person engagement; little guidance exists on engaging AIAN communities in research using virtual technologies. Our study, Native Women, Young, Strong, Empowered Changing High-risk alcohOl use and Increasing Contraception Effectiveness Study (Native WYSE CHOICES), was intentionally designed before the pandemic to be virtual, including recruitment, enrollment, intervention, and assessment with urban AIAN young women.We present our perspectives on virtual research with AIAN communities, including the critical role of our advisory partners to inform the virtual intervention design and recruitment methods in the formative stages of our project.Experiential reflection among research team and community partners.Virtual technologies, such as videoconferencing, social media, and mobile health apps, offer many tools to reach communities, especially in a pandemic. The virtualization of research with AIAN communities requires a significant investment in time, resources and planning to mitigate disadvantages; it cannot fully replace in-person-based community-based participatory research approaches, but may offer many strengths and unique advantages for research, especially in a pandemic.

One in three American Indian/Alaska Native (AI/AN) children live in poverty. This rate is higher in some reservation communities. The alarming rates of physical, mental, and social health inequities (eg, poverty) experienced by AI/AN children are symptoms of genocide, a legacy of inhumane Federal Indian policy, and ongoing structural violence. The chronically underfunded Indian Health Service (IHS) is just one example where AI/AN children are not universally guaranteed equitable health care or opportunity to thrive. Poverty is highly predictive of educational achievement, employment opportunities, violence, and ultimately health outcomes. COVID-19 has not only exacerbated physical and mental health inequities experienced by AI/AN communities, but has also intensified the economic consequences of inequity. Thus, it is vital to advocate for programs and policies that are evidence based, incorporate cultural ways of knowing, and dismantle structurally racist policies.

Problem American Indians and Alaska Natives hold a state-conferred right to health, yet significant health and health care disparities persist. Academic medical centers are resource-rich institutions committed to public service, yet few are engaged in responsive, equitable, and lasting tribal health partnerships to address these challenges. Approach Maniilaq Association, a rural and remote tribal health organization in Northwest Alaska, partnered with Massachusetts General Hospital and Harvard Medical School to address health care needs through physician staffing, training, and quality improvement initiatives. This partnership, called Siamit, falls under tribal governance, focuses on supporting community health leaders, addresses challenges shaped by extreme geographic remoteness, and advances the mission of academic medicine in the context of tribal health priorities. Outcomes Throughout the 2019-2020 academic year, Siamit augmented local physician staffing, mentored health professions trainees, provided continuing medical education courses, implemented quality improvement initiatives, and provided clinical care and operational support during the COVID-19 pandemic. Siamit began with a small budget and limited human resources, demonstrating that relatively small investments in academic-tribal health partnerships can support meaningful and positive outcomes. Next steps During the 2020-2021 academic year, the authors plan to expand Siamit's efforts with a broader social medicine curriculum, additional attending staff, more frequent trainee rotations, an increasingly robust mentorship network for Indigenous health professions trainees, and further study of the impact of these efforts. Such partnerships may be replicable in other settings, and represent a significant opportunity to advance community health priorities, strengthen tribal health systems, support the next generation of Indigenous health leaders, and carry out the academic medicine mission of teaching, research, and service.

Public Health 3.0 calls for the inclusion of new partners and novel data to bring systemic change to the US public health landscape. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has illuminated significant data gaps influenced by ongoing colonial legacies of racism and erasure. American Indian and Alaska Native (AI/AN) populations and communities have been disproportionately affected by incomplete public health data and by the COVID-19 pandemic itself. Our findings indicate that only 26 US states were able to calculate COVID-19‒related death rates for AI/AN populations. Given that 37 states have Indian Health Service locations, we argue that public health researchers and practitioners should have a far larger data set of aggregated public health information on AI/AN populations. Despite enormous obstacles, local Tribal facilities have created effective community responses to COVID-19 testing, tracking, and vaccine administration. Their knowledge can lead the way to a healthier nation. Federal and state governments and health agencies must learn to responsibly support Tribal efforts, collect data from AI/AN persons in partnership with Indian Health Service and Tribal governments, and communicate effectively with Tribal authorities to ensure Indigenous data sovereignty. (Am J Public Health. 2021;111(S3): S208–S214. https://doi.org/10.2105/AJPH.2021.306415 )

Objectives To explore health behavior profiles of AI/AN youth involved in native students together against negative decisions (STAND), a national culture-based curriculum. Methods We analyzed data from 1236 surveys conducted among AI/AN youth at 40 native STAND implementation sites located in 16 states throughout the US from 2014 to 2017. Health profiles included demographics, sexual orientation, sexual activity, STI testing, cigarette use, and suicide attempts in the past 12-months. We used t-tests and chi square tests of independence to compare risk behavior prevalence among the sample. Results Health behavior profiles of AI/AN youth indicate that 45.6% of youth did not use condoms the last time they had sex, and 82.7% have never been tested for STIs. Differences in cigarette smoking were observed in questioning youth (questioning: 80.3%, straight/heterosexual: 63.8%, LGBTQ2S + : 49.9%, p = 0.03). Conclusions for Practice Health behaviors related to sex, substance, violence and self-harm, are at least as common for AI/AN youth as those observed in other US teens. Future research should consider similarities and differences in health profiles of AI/AN youth when designing interventions that affect them. Further, our findings underscore the need for culturally-relevant curricula like native STAND, not because their health behavior is different, but because their socio-ecologic environment is different.

For more than 50 years, government programmes in the USA have been in place to help those in need have consistent access to food and education. However, questions have surfaced regarding whether or not these support impact traditional ways, such as cultural activities, food preferences, and overall health, particularly for Indigenous populations. In this paper, we share insights voiced by Alaska Native Elders in the Yukon-Kuskokwim region of Alaska and their perceptions of regulations, assistance, and the impact government assistance programmes have had on their culture. Elders raised concerns so that those administering these programmes will consider how best to meet food security and education needs without interfering with Indigenous cultural practices and traditional lifestyle.

The aim of this study was to investigate inequities in substance use disorder (SUD) diagnosis, opioid misuse, marijuana misuse, SUD treatment utilization, and utilization of university mental health services among sexual and gender minority (SGM) American Indian, Alaska Native, and Native Hawaiian (AI/AN/NH) college students.Data consisting of 8,103 AI/AN/NH students' responses to the American College Health Association's National College Health Assessment survey from fall 2015 through spring 2019 were utilized for this study. Multivariable logistic regression models were used to compare the odds of SUD diagnosis, opioid misuse, and marijuana misuse in SGM AI/AN/NH students to cisgender, heterosexual peers. Unadjusted odds of SUD treatment utilization and utilization of university mental health services were also evaluated.Compared to cisgender females, transgender (aOR = 4.43, 95% CI = 2.67-7.34) and gender diverse (aOR = 2.86, 95% CI = 1.61-5.07) students had significantly higher odds of SUD diagnosis. Similarly, significantly higher odds of SUD diagnosis were observed among sexual minorities, including gay/lesbian (aOR = 2.95, 95% CI = 1.71-5.09) and bisexual (aOR = 1.97, 95% CI = 1.30-2.99) students compared to heterosexual peers. Sexual minority students had significantly higher odds of utilizing university mental health services (uOR = 2.43, 95% CI = 1.22-4.84) than heterosexual peers. Odds of opioid misuse and marijuana misuse were also significantly increased among sexual minority students.AI/AN/NH college students who identify as SGM have higher odds of SUD diagnosis, opioid misuse, and marijuana misuse than their cisgender, heterosexual peers. These findings highlight the need to consider tailored programming for SGM AI/AN/NH students in substance use prevention and intervention efforts in U.S. college settings.

Patient-reported outcome (PRO) instruments measure the patient's perspective. It is unclear whether commonly used PRO measures were tested in populations that had racial and ethnic distributions comparable with those reported in U.S. census data.The aim of this study was to compare the proportion of non-White race and Hispanic ethnicity participants with their expected proportion based on U.S. census data for PRO instruments with U.S.-based validation studies.This was a retrospective review of PRO measures considered by the Pelvic Floors Disorders Consortium Working Group on Patient-Reported Outcomes in their 2020 consensus publication. Study and participant information were abstracted from PRO validation studies. Racial and ethnic representation in U.S.-based studies were compared with U.S. census data. The primary outcome was the representation quotient of reported races and ethnicities, calculated as the reported percentage of the study population identifying with a race and/or ethnicity divided by the proportion of the U.S. population identifying with that race and/or ethnicity when the study was published.Forty-five studies with 21,080 total participants were included. Race was reported in 17 of 45 studies (37.8%), and ethnicity was reported in 7 of 45 (15.6%). Most studies did not specify how race and ethnicity information was collected. For U.S.-based studies, the representation quotient of White participants from 1995 to 2019 was 1.15. Indigenous American/Native American/American Indian/Alaska Natives had the lowest representation quotient (0.22). Reporting of ethnicity increased over time (P = 0.001), although there was no significant change in the reporting of race or the representation of various races and ethnicities (P0.05).Non-White and Hispanic patients may be underrepresented in U.S.-based validation studies for PRO instruments in pelvic floor disorders.

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.

Background Given the increasing rates of childhood obesity in Alaska Native children and the understanding that the most effective interventions are informed by and reflect the cultural knowledge of the community in which they are implemented, this project sought to gather the wisdom of local Yup’ik and Cup’ik Elders in the Yukon-Kuskokwim region of Alaska around how to maintain a healthy diet and active lifestyle. Methods Perspectives were sought through the use of semi-structured focus groups, which were completed in person in twelve communities. All conversations were recorded, translated, transcribed, and analyzed using a qualitative approach, where key themes were identified. Results Elders provided a clear and consistent recollection of what their life looked like when they were young and expressed their perspectives related to maintaining a healthy and traditional lifestyle. The key themes the Elders discussed included an emphasis on the nutritional and cultural benefits of traditional foods; concerns around changing dietary patterns such as the consumption of processed foods and sugar sweetened beverages; and concerns on the time and use of screens. Elders also expressed a desire to help younger generations learn traditional subsistence practices. Conclusions The risk of obesity in Alaska Native children is high and intervention efforts should be grounded in local knowledge and values. The perspectives from Yup’ik and Cup’ik Elders in the Yukon-Kuskokwim Delta area of Alaska provide a better understanding on local views of how to maintain a healthy diet, physical activities, and traditional values.

Positive youth development approaches with American Indian/Alaska Native (AI/AN) youth have been particularly successful and promising. Utilizing a survey with 3,736 AI/AN students, we investigated the associations between risk and protective factors and significant mental distress of AI/AN youth. The protective factors were studied within the positive youth development framework, which includes positive developmental assets reflecting aspects of the Circle of Courage, a prior framework embodying core indigenous values for youth development and education to support youth at risk. Risk factors in the study included having experienced trauma, being bullied by peers, substance use, and skipping school; protective factors were social supports, out-of-school-time activity participation, healthy eating, and healthy sleeping behaviors. Through logistic regressions, we found that risk factors were associated with more mental distress, consistent with prior research. However, students who participated in out-of-school-time activities at least three times a week, were sleeping at least eight hours daily, and those reporting social supports, particularly family/community support and sense of empowerment, had lower likelihood of mental distress. In fact, the presence of these protective factors reduced the associations of risk factors and risky behaviors with mental distress.

This paper examines the ethical issues underlying research with urban American Indians and Alaska Natives (AI/ANs) through the lens of tribal sovereignty. There are 574 federally recognized tribes within the United States. Each of those tribes is recognized by the federal government as having sovereign status, an important political designation that ensures that decisions impacting tribal peoples must be made after consultation with those nations. Most AI/AN people live away from their designated tribal lands, yet their sovereign rights are frequently only recognized when living on tribal lands. These urban AI/ANs are still considered citizens of their sovereign nations, yet they lack the protections afforded to those who live on tribal lands, including protections surrounding research with their tribal communities. We explore the Belmont Report and related documents and demonstrate their inadequacy in considering the cultural and ethical concerns specific to protecting urban AI/ANs. We also provide several solutions to help guide future institutional policies regarding research with urban AI/ANs that honors Indigenous data sovereignty, including consultation, partnership with community advisory boards, employment of data use agreements, and ensuring informed consent.

BACKGROUND Unintentional injuries are the leading cause of death for children and youth aged 1-19 in the United States. The purpose of this report is to describe how unintentional injury death rates among children and youth aged 0-19 years have changed during 2010-2019. METHOD CDC analyzed 2010-2019 data from the National Vital Statistics System (NVSS) to determine two-year average annual number and rate of unintentional injury deaths for children and youth aged 0-19 years by sex, age group, race/ethnicity, mechanism, county urbanization level, and state. RESULTS From 2010-2011 to 2018-2019, unintentional injury death rates decreased 11% overall-representing over 1,100 fewer annual deaths. However, rates increased among some groups-including an increase in deaths due to suffocation among infants (20%) and increases in motor-vehicle traffic deaths among Black children (9%) and poisoning deaths among Black (37%) and Hispanic (50%) children. In 2018-2019, rates were higher for males than females (11.3 vs. 6.6 per 100,000 population), children aged

This article discusses a community-based participatory research project with university researchers, an urban inter-tribal center, and other community partners to develop, administer, and deliver a community needs assessment of an urban American Indian (AI) community. In the development process, community focus groups identified major domains of inquiry for a needs assessment survey: mental health and substance abuse, medical care, and social services, including cultural programming. Results are presented and discussed in each domain. Overall, this community needs assessment contributes to a better understanding of American Indian and Alaska Native (AI/AN) urban challenges by providing information about the AI/AN population in a large southwest metropolitan area. Specifically, it highlights the relevance of local and state contexts for understanding issues facing AI/AN populations. A growing body of research indicates that AI/AN populations demonstrate some similar challenges in terms of health, social service needs, and mental health and substance abuse needs due to shared histories of colonization and misguided or underfunded government programs, among other factors. It remains true that AI/AN communities nonetheless are each distinctive and face unique challenges and opportunities within the local, state, and regional contexts in which they reside. The process described in this paper will inform policy, practice, and research communities interested in understanding the unique realities of an urban community representing many different AI tribes.

OBJECTIVE: To identify risk factors for postpartum hemorrhage in a population of Alaska Native women. METHODS: A case control study of 384 women (128 cases, 256 controls) delivering between August 1, 2018, and July 31, 2019 was conducted at a Level III maternal referral center for Alaska Native women in Alaska. Risk factors were assessed via retrospective chart review, and bivariate and conditional regression analysis were conducted to determine odds ratios (ORs) between women with and without postpartum hemorrhage. RESULTS: Body mass index ≥40 (OR 2.6; 95% confidence interval [CI: 1.4–4.5), antepartum bleeding (OR 6.3; 95% CI 1.2–31.6), previous postpartum hemorrhage (OR 5; 95% CI 2.6–9.8), suspected macrosomia (OR 2.7; 95% CI 1.4–5.3), macrosomia with birthweight ≥4000 g (OR 3.1; 95% CI 1.8–5.3), pre-eclampsia with magnesium sulfate (OR 4.0; 95% CI 2.0–8.0), length of 3(rd) stage of labor >20 minutes (OR 2.2; 95% CI 1.1–4.4), oxytocin use >12 hours (OR 5.4; 95% CI 2.0–14.6), residence in a rural community (OR 2.2; 95% CI 1.4–3.6) and vitamin D supplementation (OR 1.7; 95% CI 1.1–2.6) were associated with greater risk of postpartum hemorrhage. CONCLUSION: Analysis of clinical and geographic risk factors for postpartum hemorrhage in Alaska Native women identified important targets for prevention.

The opioid crisis in the United States has received national attention and critical resources in the past decade. However, what has been overlooked is the effect the opioid crisis may be having on a three-decade suicide crisis among American Indian and Alaska Native (AIAN) communities that already have too few resources to address behavioral and mental health issues. This paper describes recent epidemiological trends associated with both opioid overdose and suicide at a national level for AIANs and the rest of the United States. We used data reported by the Centers for Disease Control and Prevention to report historical trends of opioid overdose and suicide for AIAN and non-AIAN populations. We found alarming and potentially correlated trends of opioid use and suicidality among AIAN populations. We highlight both current and future research that will be essential to understanding and addressing the unique intersection between opioid and suicide risk and protective factors to inform dual prevention and intervention efforts among AIAN populations with potential relevance to public health response among other at-risk populations.

Objective Characterize vegetable and fruit (VF) intake in a Yup'ik community using self-reported intake and skin carotenoid status (SCS) and evaluate the relationship between SCS and fish intake. Methods Self-reported VF intake was measured using the 24-hour recall, SCS was measured by reflection spectroscopy via the Veggie Meter (Longevity Link Corporation), and fish intake was estimated by the nitrogen isotope ratio (NIR) for 80 participants in a remote community in Southwestern Alaska. Bivariate correlations were used to assess the relationship between self-reported VF intake, SCS, and NIR. Results Intake of all VF subgroups was low. The SCS was higher for males (262.7 vs 185.3; P = 0.002) and participants consuming more than 1 VF serving (232.5 vs 183.0; P = 0.02). It was not associated with the NIR. Conclusions and Implications Increasing VF intake is a way to improve diet in Yup'ik communities and the Veggie Meter is a simple and noninvasive tool to facilitate surveillance efforts.

Objectives: Home blood pressure monitoring (HBPM) is an important component of blood pressure (BP) management. We assessed performance of two HBPM devices among Alaska Native and American Indian people (ANAIs). Methods: We measured BP using Omron BP786 arm cuff, Omron BP654 wrist cuff, and Baum aneroid sphygmomanometer in 100 ANAIs. Performance was assessed with intraclass correlation, paired t-tests, and calibration models. Results: Compared to sphygmomanometer, average BP was higher for wrist cuff (systolic = 4.8 mmHg and diastolic = 3.6 mmHg) and varied for arm cuff (systolic = −1.5 mmHg and diastolic = 2.5 mmHg). Calibration increased performance from grade B to A for arm cuff and from D to B for wrist cuff. Calibration increased false negatives and decreased false positives. Discussion: The arm HBPM device is more accurate than the wrist cuff among ANAIs with hypertension. Most patients are willing to use the arm cuff when accuracy is discussed.

Objective: To examine stakeholder perspectives on food insecurity and associated challenges to healthy eating among American Indian and Alaska Native (AI/AN) adults with type 2 diabetes (T2D). Methods: Focus groups and interviews were conducted with purposively selected stakeholders: AI/ANs with T2D, their family members, healthcare administrators, nutrition and diabetes educators, and national content experts on AI/AN health. Two coders analyzed transcripts using the constant-comparison method. Results: Key themes included (1) rural- and urban-dwelling AI/ANs experience different primary food security and associated challenges; (2) factors contributing to food insecurity extend beyond cost of healthy food; and (3) barriers to consuming fresh, healthy food include cost, preparation time, limited cooking knowledge, and challenges with gardening. Discussion: Resources for AI/ANs with T2D who experience food insecurity and associated challenges to healthy eating should be tailored based on urban versus rural location and should address cost and other barriers to consumption of fresh fruits and vegetables.

Objective: To examine self-rated health and activities of daily living (ADLs) limitations among American Indian and Alaska Native (AI/AN) veterans relative to white veterans. Methods: We use the 2010 National Survey of Veterans and limit the sample to veterans who identify as AI/AN or non-Hispanic white. We calculated descriptive statistics, confidence intervals, and used logistic regression. Results: AI/AN veterans are younger, have lower levels of income, and have higher levels of exposure to combat and environmental hazards compared to white veterans. We found that AI/AN veterans are significantly more likely to report fair/poor health controlling for socioeconomic status and experience an ADL controlling for age, health behaviors, socioeconomic status, and military factors. Discussion: The results indicate that AI/AN veterans are a disadvantaged population in terms of their health and disability compared to white veterans. AI/AN veterans may require additional support from family members and/or Veteran Affairs to address ADLs.

There is a paucity of data regarding racial disparities in the survival of patients with indolent non-Hodgkin lymphomas (iNHL) in the contemporary time-period. Hence, we sought to determine whether racial disparities exist in the survival of patients with iNHLs in the US. We included 68,059 adult patients with follicular lymphoma (FL, n=41,943), marginal zone lymphoma (MZL, n=22,485), and lymphoplasmacytic lymphoma/Waldenstrom macroglobulinemia (LPL/WM, n=3,631) who were diagnosed in the US between 2000-2017. Race was categorized as White, Black, Asian/Pacific Islander, or American Indian/Alaska Native (API/AI). The primary outcome was relative survival (RS), which was estimated using flexible parametric survival models. RS estimates varied according to race and disease histology but were consistently lower for racial minorities, including those diagnosed during the most recent 5-year time-period of 2012-2017. On multivariable analysis for RS, Black patients with FL had a 32% higher excess mortality rate compared to White patients [adjusted excess hazard ratio (aEHR), 1.32; 95% CI, 1.15-1.51; P

SUMMARY The persistence of health care disparities along racial and ethnic lines highlights the complex and multifactorial nature of this national concern. The paucity of physicians ethnically underrepresented in medicine to treat an ever-growing heterogeneous population inherently contributes to these ongoing disparities. The authors proposed an approach to improve the representation of physicians underrepresented in medicine in their plastic surgery residency program. With a renewed commitment to ethnic diversity and inclusion, a multifaceted recruitment and retention approach was implemented at the University of Pennsylvania plastic and reconstructive surgery residency program from 2015 to 2020 (5 academic years). A retrospective review of the demographics of the program's residents was then assessed over the past 9 academic years for comparison (2011 to 2020). The representation of underrepresented-in-medicine residents within the plastic and reconstructive surgery residency program steadily increased with the implementation of this multifaceted approach, reaching an unprecedented high. Currently, 29 percent of all residents are underrepresented in medicine and 29 percent are female, some of whom are also underrepresented in medicine. Although the female representation is on par with the national average, the underrepresented-in-medicine representation is far greater than the national average. As a result of this multifaceted approach, the representation of African American and Latino plastic surgery residents at the University of Pennsylvania now far exceeds current national averages. Unfortunately, the representation of Native American and Alaskan Natives is still lacking, despite the program's broadened recruitment efforts. The success of this experience describes a successful strategy that institutions can implement to enhance underrepresented-in-medicine representation among its plastic surgery trainees.

Objective Epidemiologic data on systemic lupus erythematosus (SLE) are limited, particularly for racial/ethnic subpopulations in the US. This meta-analysis leveraged data from the Centers for Disease Control and Prevention (CDC) National Lupus Registry network of population-based SLE registries to estimate the overall prevalence of SLE in the US. Methods The CDC National Lupus Registry network includes 4 registries from unique states and a fifth registry from the Indian Health Service. All registries defined cases of SLE according to the American College of Rheumatology (ACR) 1997 revised classification criteria for SLE. Case findings spanned either 2002-2004 or 2007-2009. Given the heterogeneity across sites, a random-effects model was used to calculate the pooled prevalence of SLE. An estimate of the number of SLE cases in the US was generated by applying sex/race-stratified estimates to the 2018 US Census population. Results In total, 5,417 cases were identified as fulfilling the ACR SLE classification criteria. The pooled prevalence of SLE from the 4 state-specific registries was 72.8 per 100,000 person-years (95% confidence interval [95% CI] 65.3-81.0). The prevalence estimate was 9 times higher among females than among males (128.7 versus 14.6 per 100,000), and highest among Black females (230.9 per 100,000), followed by Hispanic females (120.7 per 100,000), White females (84.7 per 100,000), and Asian/Pacific Islander females (84.4 per 100,000). Among males, the prevalence of SLE was highest in Black males (26.7 per 100,000), followed by Hispanic males (18.0 per 100,000), Asian/Pacific Islander males (11.2 per 100,000), and White males (8.9 per 100,000). The American Indian/Alaska Native population had the highest race-specific SLE estimates, both among females (270.6 per 100,000) and among males (53.8 per 100,000). In 2018, an estimated 204,295 individuals (95% CI 160,902-261,725) in the US fulfilled the ACR classification criteria for SLE. Conclusion A coordinated network of population-based SLE registries provides more accurate estimates of the prevalence of SLE and the numbers of individuals affected with SLE in the US in 2018.

Health advocates are increasingly using social media and mobile technology to reach American Indian and Alaska Native (AI/AN) youth to address important health topics and enhance protective factors. Public health experts did not know to what extent AI/AN youth used these tools to access health resources during the pandemic. The Native Youth Health Tech Survey was administered online from October to November 2020 with 349 AI/AN youth 15 to 24 years old. Survey results indicated frequent technology use-68.7% sent 1-50 text messages per day, and 65.3% were on social media 3-7 hours per day. Instagram was the most popular channel used, and 53.5% of participants relied heavily on the Internet to access health information. The three most important health topics were Native identity, mental health, and social justice and equality. These findings can inform the design and dissemination of culturally grounded health resources across AI/AN communities to improve their reach and appeal, improving health outcomes, self-esteem, and cultural connectedness.