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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.

Background American Indian/Alaska Native (AI/AN) populations have been disproportionately affected by chronic respiratory diseases for reasons incompletely understood. Past research into disease disparity using population-based surveys mostly focused on state-specific factors. The present study investigates the independent contributions of AI/AN racial status and other socioeconomic/demographic variables to chronic respiratory disease disparity in an 11-state region with historically high AI/AN representation. Using data from the Behavioral Risk Factor Surveillance System (BRFSS) spanning years 2011–2018, this work provides an updated assessment of disease disparity and potential determinants of respiratory health in AI/AN populations. Methods This cross-sectional study used data from the BRFSS survey, 2011–2018. The study population included AI/AN and non-Hispanic white individuals resident in 11 states with increased proportion of AI/AN individuals. The yearly number of respondents averaged 75,029 (62878–87,350) which included approximately 5% AI/AN respondents (4.5–6.3%). We compared the yearly adjusted prevalence for chronic respiratory disease, where disease status was defined by self-reported history of having asthma and/or chronic obstructive pulmonary disease (COPD). Multivariable logistic regression was performed to determine if being AI/AN was independently associated with chronic respiratory disease. Covariates included demographic (age, sex), socioeconomic (marital status, education level, annual household income), and behavioral (smoking, weight morbidity) variables. Results The AI/AN population consistently displayed higher adjusted prevalence of chronic respiratory disease compared to the non-Hispanic white population. However, the AI/AN race/ethnicity characteristic was not independently associated with chronic respiratory disease (OR, 0.93; 95% CI, 0.79–1.10 in 2017). In contrast, indicators of low socioeconomic status such as annual household income of Conclusions This study highlighted that AI/AN socioeconomic burdens are key determinants of chronic respiratory disease, in addition to well-established risk factors such as smoking and weight morbidity. Disease disparity experienced by the AI/AN population is therefore likely a symptom of disproportionate socioeconomic challenges they face. Further promotion of public health and social service efforts may be able to improve AI/AN health and decrease this disease disparity.

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.

The ongoing challenge of American Indian and Alaska Native (AIAN) youth suicide is a public health crisis of relatively recent historical origin inadequately addressed by contemporary prevention science. A promising development in AIAN suicide prevention highlights the role of protective factors. A protective factor framework adopts a social ecological perspective and community-level intervention paradigm. Emphasis on protection highlights strength-based AIAN cultural strategies in prevention of youth suicide. Attention to multiple intersecting levels incorporates strategies promoting community as well as individual resilience processes, seeking to influence larger contexts as well as individuals within them. This approach expands the scope of suicide prevention strategies beyond the individual level and tertiary prevention strategies. Interventions that focus on mechanisms of protection offer a rigorous, replicable, and complementary prevention science alternative to risk reduction approaches. This selected review critically examines recent AIAN protective factor suicide prevention science. One aim is to clarify key concepts including protection, resilience, and cultural continuity. A broader aim is to describe the evolution of this promising new framework for conducting primary research about AIAN suicide, and for designing and testing more effective intervention. Recommendations emphasize focus on mechanisms, multilevel interactions, more precise use of theory and terms, implications for new intervention development, alertness to unanticipated impacts, and culture as fundamental in a protective factors framework for AIAN suicide prevention. A protective factor framework holds significant potential for advancing AIAN suicide prevention and for work with other culturally distinct suicide disparity groups, with broad implications for other areas of prevention science.

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.

Introduction Opioid use disorder has grown rapidly over the years and is a public health crisis in the U.S. Although opioid use disorder is widely studied, relatively little is known about it among older adults. The goal of this study is to gain a better understanding of opioid use disorder among older Medicare beneficiaries over time and across several sociodemographic dimensions. Methods Data from the 2013–2018 Centers for Medicare & Medicaid Services Master Beneficiary Summary Files were analyzed in 2020 to examine the trends in opioid use disorder prevalence among Fee-for-Service Medicare beneficiaries aged ≥65 years. Utilizing the overarching opioid use disorder flag, trends in opioid use disorder prevalence were examined for the following sociodemographic dimensions: age, sex, race/ethnicity, and dual eligibility status (i.e., enrolled in both Medicare and Medicaid owing to low income). Chi-square tests were used to compare opioid use disorder prevalence across groups. Results Since 2013, estimated rates of opioid use disorder among older adults have increased by >3-fold overall in the U.S. Estimated opioid use disorder is more prevalent among the young–old (i.e., ages 65–69 years) beneficiaries than among other older adults, and dually eligible beneficiaries have consistently shared a heavier burden of opioid use disorder than Medicare-only beneficiaries. Regarding race/ethnicity, Blacks and American Indians/Alaskan Natives are more vulnerable to opioid use disorder than other groups. Conclusions The descriptive trends between 2013 and 2018 indicate that estimated opioid use disorder prevalence has increased greatly over the study period in all sociodemographic subgroups of older adults, highlighting an urgent challenge for public health professionals and gerontologists.

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.

Background Diabetes, hypertension, and cardiovascular disease (CVD) are modifiable lifestyle-related cardiometabolic conditions associated with dementia. Yet, little is known regarding these associations among American Indian and Alaska Native (AI/AN) people. Thus, we examined the association of diabetes, hypertension, and CVD with all-cause dementia among AI/ANs aged 65 years and older. Method This was a cross-sectional analysis of the Indian Health Service Improving Health Care Delivery Data Project. Our study population was a 1:1 matched sample of 4 074 AI/ANs aged 65 years and older and Indian Health Service active users during fiscal year 2013. We employed International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes for all-cause dementia, hypertension, and CVD. Diabetes was measured with a validated algorithm to identify adults with diabetes that uses diagnoses, laboratory test results, and medication criteria. Results Multivariable analyses revealed that diabetes and CVD were associated with increased odds of all-cause dementia and hypertension was not. Cardiovascular disease types associated with all-cause dementia differed with cerebrovascular disease having the strongest association. Analyses stratified by gender revealed that diabetes and CVD were associated with increased odds of all-cause dementia for women and only CVD was associated with all-cause dementia for men. Conclusions Training and support of primary care clinicians, addressing cultural considerations, and ensuring inclusion of AI/ANs in research are steps that could help meet AI/AN people’s needs. Our findings underscore to the importance of improved management and control of diabetes and CVD, which may lead to the prevention of dementia among older AI/ANs.

Background: Maternal mortality decreased globally by about 38% between 2000 and 2017, yet, it continues to climb in the United States. Gaping disparities exist in U.S. maternal mortality between white (referent group) and minority women. Despite important and appropriate attention to disparities for black women, almost no attention has been given to American Indian/Alaska Native (AI/AN) women. The purpose of this scoping review is to synthesize available literature concerning AI/AN maternal mortality. Methods: Databases were searched using the terms maternal mortality and pregnancy-related death, each paired with American Indian, Native American, Alaska Native, Inuit, and Indigenous. Criteria (e.g., hemorrhage) were paired with initial search terms. Next, pregnancy-associated death was paired with American Indian, Native American, Alaska Native, Inuit, and Indigenous. Criteria in this category were homicide, suicide, and substance use. Results: The three leading causes of AI/AN pregnancy-related maternal mortality are hemorrhage, cardiomyopathies, and hypertensive disorders of pregnancy. AI/AN maternal mortality data for homicide and suicide consistently include small samples and often categorize AI/AN maternal deaths in an "Other" race/ethnicity, which precludes targeted AI/AN data analysis. No studies that reported AI/AN maternal mortality as a result of substance use were found. Health care characteristics such as quality, access, and location also may influence maternal outcomes and maternal mortality. Conclusions: Despite AI/AN maternal mortality being disproportionately high compared to other racial/ethnic groups, relatively little is known about root causes.

Introduction Adverse childhood experiences are linked to deleterious outcomes in adulthood. Certain populations have been shown to be more vulnerable to adversity in childhood than others. Despite these findings, research in this area lacks an empirical investigation that examines adverse childhood experiences among American Indian and Alaska Native populations using large, nationally representative data. As such, the authors have compiled what they believe is the largest empirical investigation of adverse childhood experiences among American Indian and Alaska Native individuals to date. Methods Data were collected from the Behavioral Risk Factor Surveillance System from 34 states (2009–2017), whereby all individuals self-report as American Indian and Alaska Native (N=3,894). Adverse childhood experience scores were calculated and further stratified by sex, age, household income, education, employment status, sexual orientation, Census region, and state. In addition, frequencies and prevalence of each adverse childhood experience domain (stratified by the same categories) were calculated. Analysis was conducted in 2019. Results The average adverse childhood experience score among American Indians and Alaska Natives was 2.32, higher than those of individuals identifying as White (1.53), Black (1.66), and Hispanic (1.63). Female participants had a higher average adverse childhood experience score than male participants (2.52 vs 2.12). Generally, younger individuals and those with lower incomes reported higher adverse childhood experience scores, whereas those with higher educational attainment reported lower scores. Conclusions Compared with the few studies among American Indian and Alaska Native populations that have used either smaller samples or nontraditional adverse childhood experience data (i.e., asking parents about their children's experiences), these results present overall higher adverse childhood experience averages than previously published studies. Nevertheless, aligning with other research on adverse childhood experiences, female individuals, younger adults, and sexual minorities reported higher adverse childhood experiences scores than other categories in their respective demographics.

The population of the United States is aging and by 2045 it is projected that approximately 1 in every 6 Alaskans will be 65+. Delivering healthcare and meeting the needs of older Alaskans in their community is critical to supporting healthy aging and community sustainability. Alaska Native (AN) Elders are underserved with very few studies providing an emic perspective on their experience aging. This research opens the door and allows us a glimpse of the AN Elder experience of aging: the values, beliefs, and behaviors that allow them to age well. This study highlights the characteristics and activities of AN Elders in the Aleutian and Pribilof Islands to further develop the model of AN successful aging. There are many theories of aging and this study explores a cross-cultural understanding of gerotranscendence - the personal and interpersonal changes that result from successful aging or achieving Eldership. This study interviewed Elders in two communities of the Aleutian and Pribilof Islands region. Using 22 standardized questions based on the explanatory model, researchers facilitated discussion of what it means to be an Elder and age successfully. Employing thematic analysis, interview transcripts were analyzed for themes to organize the data. Themes were organized into 5 core elements of successful aging with specific emphasis on values, beliefs, and behaviors that were protective and helped them adapt to aging-related changes. Interview content, meaning, and themes support the four elements of the AN model of successful aging developed by Lewis (The Gerontologist, 51(4), 540-549, 2011): Mental and Emotional Wellbeing, Spirituality, Purposefulness and Engagement, and Physical Health. Elders’ stories highlight the importance of reflection, personal growth, and psychosocial development. Elders who more strongly identified with their role in the community described how their perspective had changed and they shared stories that emphasized culture, connection to the land, and enjoyment of daily activities that resulted in increased life satisfaction. Elders provided clear evidence that they experienced aspects of gerotranscendence, which Tornstam (Journal of Aging Studies, 11(2), 143-154, 1997) categorized as the cosmic dimension, the self, and social and personal relationships. Elders adapting to aging-related changes and embracing their role as an Elder provided the greatest evidence of gerotranscendence - they developed new perspectives on life, took on new roles within the community, and experienced a shift in mindset that reinforced the importance of culture, tradition, and the Native Way of Life. This research allowed AN Elders to share their experiences, define successful aging, and expand the concept of Eldership to include changes in mindset, values, and relationships with themselves and others. The study is a framework to help us better understand the experiences of AN Elders aging successfully and the wisdom they wish to impart to others to help them learn to live healthy and meaningful lives.

In this study, positive aspects of self-compassion (i.e., self-kindness, common humanity, and mindfulness of one's thoughts and feelings) were explored in relation with suicide risk factors (i.e., perceived burdensomeness and thwarted belongingness) in a community sample of 242 self-identified American Indian/Alaska Native (AI/AN) adults. Participants completed a survey packet including a demographic form, the Interpersonal Needs Questionnaire, and the Self-Compassion Scale at several Indian Health Service clinics and tribal centers in the Great Plains of the United States. Results indicated that positive aspects of self-compassion (i.e., self-kindness, common humanity, and mindfulness) were associated with and predictive of less suicide risk (i.e., less perceived burdensomeness and thwarted belongingness) among AI/AN adults. Of those with a history of suicidal ideation (n = 89), positive aspects of self-compassion were predictive of less perceived burdensomeness, but were not predictive of thwarted belongingness. Implications for prevention and intervention programs that emphasize self-compassion, mindfulness, and culturally relevant practices, as well as mental health advocacy, including suicide prevention, for AI/AN people are highlighted.

Meaningful engagement of Alaska Native (AN) tribes and tribal health organizations is essential in the conduct of socially responsible and ethical research. As genomics becomes increasingly important to advancements in medicine, there is a risk that populations not meaningfully included in genomic research will not benefit from the outcomes of that research. AN people have historically been underrepresented in biomedical research; AN underrepresentation in genomics research is compounded by mistrust based on past abuses, concerns about privacy and data ownership, and cultural considerations specific to this type of research. Working together, the National Human Genome Research Institute and two Alaska Native health organizations, Southcentral Foundation and the Alaska Native Health Board, cosponsored a workshop in July 2018 to engage key stakeholders in discussion, strengthen relationships, and facilitate partnership and consideration of participation of AN people in community-driven biomedical and genomic research. AN priorities related to translation of genomics research to health and health care, return of genomic results, design of research studies, and data sharing were discussed. This report summarizes the perspectives that emerged from the dialogue and offers considerations for effective and socially responsible genomic research partnerships with AN communities.

Rural Indigenous communities in Alaska suffer staggeringly high rates of suicide. In close-knit Alaska Native villages, each suicide leaves a trail of affected family and community members in its wake. This research aimed to understand community perceptions of what causes suicide in rural Alaska Native villages and generate recommendations for prevention strategies. In-depth interviews were conducted with 25 Alaska Native university students who moved from rural villages to an urban area to attend college. All had been profoundly affected by others' suicides and shared their beliefs about causal factors and recommendations for prevention efforts. Perceived causes included resistance to seeking help or discussing personal problems, loss of culture, traumatic experiences, geographical and social isolation, lack of opportunity, substance abuse, and exposure to others' suicides. Participants believed that suicide is preventable and recommended multi-level approaches to address suicide disparities. They provided recommendations for potentially effective and culturally appropriate prevention strategies, including increasing cultural and social connections, educating community members about mental health, and increasing accessibility of counseling services/reducing barriers to mental health services utilization. Monica C. Skewes et al, Beliefs about causal factors for suicide in rural Alaska Native communities and recommendations for prevention, Transcultural Psychiatry (, ) pp. . Copyright © 2020. DOI: 10.1177/1363461520963869. Users who receive access to an article through a repository are reminded that the article is protected by copyright and reuse is restricted to non-commercial and no derivative uses. Users may also download and save a local copy of an article accessed in an institutional repository for the user's personal reference. For permission to reuse an article, please follow our Process for Requesting Permission. Deposited by shareyourpaper.org and openaccessbutton.org. We've taken reasonable steps to ensure this content doesn't violate copyright. However, if you think it does you can request a takedown by emailing help@openaccessbutton.org.

PURPOSE The purpose of this study was to gain insight into the experiences of Native American cancer survivors in navigating life after cancer and what resources and strategies survivors found useful for coping and achieving optimal quality of life (QoL) after diagnosis (the terms “Native Americans” and “Natives” are used interchangeably in this article to describe American Indians and Alaska Natives). The research questions were What advice and words of wisdom do Native cancer survivors prioritize in messages to other Native cancer survivors? and What do those messages reveal about how Native cancer survivors interpret, experience, and restore QoL after diagnosis? METHODS This study used a qualitative phenomenologic descriptive study design. Researchers used thematic analysis to identify themes related to peer advice and QoL from transcripts of semi-structured interviews with 52 geographically and clinically diverse Native cancer survivors in the United States. RESULTS Survivors’ lived experiences directly informed their advice to other survivors, which was characterized by four themes: listen to your body, advocate for yourself, embrace your culture and spirituality, and share your story. A deeper look into the origins of those messages revealed challenges survivors face balancing their responsibility to care for themselves while simultaneously embracing cultural values of selflessness. CONCLUSION Providers and researchers should work with Native cancer survivors to identify and leverage existing community strengths in ways that support all aspects of a survivors’ QoL rather than limiting support to a single QoL domain (eg, physical, spiritual, mental/emotional, or social issues). Interventions should ensure that supports and services align with survivors’ cultural values and attend to competing responsibilities to optimize QoL.

IntroductionAlcohol and drug use are significant problems in the US, and American Indian/Alaska Native (AI/AN) communities and individuals are known to be among the most affected. This study evaluates disparities in unintentional injury mortality causes since 1999.MethodsAnalyses in 2020 of unintentional injury mortality rate disparities between AI/ANs and white population over the 1999–2016 period with attention to motor vehicle crashes, alcohol poisoning, drug poisoning and all other cause types. Rates in each of the 10 states with the largest AI/AN populations were also investigated to account for geographical concentration.ResultsMotor vehicle mortality rates declined for both AI/AN and white groups, but a large racial disparity was maintained. Conversely, poisoning mortality rates rose substantially in both groups, with a jump in rates in 2007 due to a coding change, resulting in a large disparity that was maintained through 2016. Comparison of alcohol and drug poisonings showed that the AI/AN alcohol poisoning rate was about eight times the white rate, whereas drug poisoning rates were similar. For ‘all other’ unintentional injuries, the highest rates were seen for AI/AN men, with rates generally rising over the study period. State-specific analyses found substantial variation in AI/AN rates, with few or no disparities in New York and Texas.ConclusionsResults indicate substantial and persisting disparities in unintentional injury mortality, with especially large differences in alcohol poisoning. The absence of disparities in New York and Texas suggest the importance of situational factors.

Cancer incidence varies among American Indian and Alaska Native (AI/AN) populations, as well as between AI/AN and White populations. This study examined trends for cancers with elevated incidence among AI/AN compared with non-Hispanic White populations and estimated potentially avoidable incident cases among AI/AN populations. Incident cases diagnosed during 2012–2016 were identified from population-based cancer registries and linked with the Indian Health Service patient registration databases to improve racial classification of AI/AN populations. Age-adjusted rates (per 100,000) and trends were calculated for cancers with elevated incidence among AI/AN compared with non-Hispanic White populations (rate ratio of >1.0) according to region. Trends were estimated using joinpoint regression analyses. Expected cancers were estimated by applying age-specific cancer incidence rates among non-Hispanic White populations to population estimates for AI/AN populations. Excess cancer cases among AI/AN populations were defined as observed minus expected cases. Liver, stomach, kidney, lung, colorectal, and female breast cancers had higher incidence rates among AI/AN populations across most regions. Between 2012 and 2016, nearly 5,200 excess cancers were diagnosed among AI/AN populations, with the largest number of excess cancers (1,925) occurring in the Southern Plains region. Culturally informed efforts could reduce cancer disparities associated with these and other cancers among AI/AN populations.

Problem American Indian/Alaska Native (AI/AN) populations are facing multiple health crises, including limited access to care, high rates of chronic disease, and early mortality that is far worse than other underrepresented minorities in the U.S. According to the Association of American Indian Physicians, AI/AN people represent 2.0% of the U.S. population but only 0.2% of medical students and 0.1% of full-time faculty at MD-granting institutions. Increasing the number of AI/AN clinicians and scientists is one strategy to improve health outcomes in the AI/AN population and address these crises. Approach In 2010, the University of Utah partnered with research, cultural, and professional mentors to create a 10-week summer Native American Research Internship (NARI) program for AI/AN college students across the U.S. who are interested in pursuing biomedical careers. NARI attracts and supports AI/AN students by offering mentored summer research internships in an innovative, culturally-aware framework that adapts to observed challenges to optimize educational experiences and support biomedical career aspirations. Outcomes During the first decade of the NARI program, 128 students from 22 U.S. states, representing 46 tribal nations and 57 colleges and universities, have participated. Of those 128 students, 113 (88%) have completed a bachelor's degree and the remaining 15 (12%) are currently working towards a bachelor's degree. No NARI student has dropped out of college. Twenty-six (20%) NARI alumni have matriculated to medical school and 30 (23%) to graduate school. Eight (6%) participants have completed medical school and 3 (2%) participants are pursuing a PhD in science. An additional 36 (28%) have gained employment in biomedical research fields. Next steps The NARI program has increased the participation of AI/AN students in medicine and the biomedical sciences. The innovative, culturally-aware, and adaptive framework is a model for other programs for AI/AN students and students in other underrepresented communities.

Background Mammography use is affected by multiple factors that may change as public health interventions are implemented. We examined two nationally representative, population‐based surveys to seek consensus and identify inconsistencies in factors associated with mammography use in the entirety of the US population, and by black and white subgroups. Methods Self‐reported mammography use in the past year was extracted for 12 639 and 169 116 women aged 40‐74 years from the 2016 National Health Interview Survey (NHIS) and the 2016 Behavioral Risk Factor Surveillance System (BRFSS), respectively. We applied a random forest algorithm to identify the risk factors of mammography use and used a subset of them in multivariable survey logistic regressions to examine their associations with mammography use, reporting predictive margins and effect sizes. Results The weighted prevalence of past year mammography use was comparable across surveys: 54.31% overall, 54.50% in white, and 61.57% in black in NHIS and 53.24% overall, 56.97% in white, and 62.11% in black in BRFSS. Overall, mammography use was positively associated with black race, older age, higher income, and having health insurance, while negatively associated with having three or more children at home and residing in the Western region of the US. Overweight and moderate obesity were significantly associated with increased mammography use among black women (NHIS), while severe obesity was significantly associated with decreased mammography use among white women (BRFSS). Conclusion We found higher mammography use among black women than white women, a change in the historical trend. We also identified high parity as a risk factor for mammography use, which suggests a potential subpopulation to target with interventions aimed at increasing mammography use., Different from the historical trend, we found higher mammography use among black women than white women. We identified high parity as a risk factor for mammography use, which is less known and suggests a potential subpopulation for targeted interventions.

Objective In the United States, HPV vaccination is routinely recommended at age 11 or 12 years; the series can be started at age 9. We conducted a cohort study to assess long-term immunogenicity of quadrivalent HPV vaccine (4vHPV) in an American Indian/Alaska Native (AI/AN) Indigenous population. Methods During 2011–2014, we enrolled AI/AN girls and boys aged 9–14 years, who were vaccinated with a 3-dose series of 4vHPV. Serum specimens were collected at five time points: immediately prior to doses 2 and 3, and at one month, one year, and two years after series completion. Antibody testing was performed using a multiplex virus-like-particle-IgG ELISA for 4vHPV types (HPV 6/11/16/18). Results Among 477 children (405 girls/72 boys) completing the 3-dose series, median age at enrollment was 11.2 years. Of the 477, 72 (15%) were tested before dose 2 and 70 (15%) before dose 3. Following series completion, 435 (91%) were tested at one month, 382 (80%) at one year, and 351 (74%) at two years. All tested participants had detectable antibody to 4vHPV types at all time points measured. Geometric mean concentrations (GMCs) for 4vHPV types at one month and two years post-series completion were 269.9 and 32.7 AU/ml for HPV6, 349.3 and 42.9 AU/ml for HPV11, 1240.2 and 168.3 IU/ml HPV16, and 493.2 and 52.2 IU/ml for HPV18. Among children tested after each dose, GMCs after doses 1 and 2 were 3.9 and 32.2 AU/ml for HPV6, 5.3 and 45.6 AU/ml for HPV11, 20.8 and 187.9 IU/ml for HPV16; and 6.6 and 49.7 IU/ml for HPV18. No serious adverse events were reported. Conclusion All AI/AN children developed antibodies to all 4vHPV types after vaccination. GMCs rose after each dose, then decreased to a plateau over the subsequent two years. This cohort will continue to be followed to determine duration of antibody response.

Although non-Hispanic American Indian and Alaska Native (AI/AN) persons account for 0.7% of the U.S. population,* a recent analysis reported that 1.3% of coronavirus disease 2019 (COVID-19) cases reported to CDC with known race and ethnicity were among AI/AN persons (1). To assess the impact of COVID-19 among the AI/AN population, reports of laboratory-confirmed COVID-19 cases during January 22†-July 3, 2020 were analyzed. The analysis was limited to 23 states§ with >70% complete race/ethnicity information and five or more laboratory-confirmed COVID-19 cases among both AI/AN persons (alone or in combination with other races and ethnicities) and non-Hispanic white (white) persons. Among 424,899 COVID-19 cases reported by these states, 340,059 (80%) had complete race/ethnicity information; among these 340,059 cases, 9,072 (2.7%) occurred among AI/AN persons, and 138,960 (40.9%) among white persons. Among 340,059 cases with complete patient race/ethnicity data, the cumulative incidence among AI/AN persons in these 23 states was 594 per 100,000 AI/AN population (95% confidence interval [CI] = 203-1,740), compared with 169 per 100,000 white population (95% CI = 137-209) (rate ratio [RR] = 3.5; 95% CI = 1.2-10.1). AI/AN persons with COVID-19 were younger (median age = 40 years; interquartile range [IQR] = 26-56 years) than were white persons (median age = 51 years; IQR = 32-67 years). More complete case report data and timely, culturally responsive, and evidence-based public health efforts that leverage the strengths of AI/AN communities are needed to decrease COVID-19 transmission and improve patient outcomes.

Background and aims Many evidence-based treatments (EBTs) for substance use disorder (SUD) exist, yet few are tailored to Indigenous patients. This trial tested the efficacy of a culturally tailored EBT that combined Motivational Interviewing and the Community Reinforcement Approach (MICRA) versus treatment as usual (TAU). Design A mixed efficacy/effectiveness randomized controlled trial of MICRA (n = 38) and TAU (n = 41) using a parallel design with follow-up assessments at 4-, 8-, and 12- months post baseline. Setting United States, reservation-based outpatient, addiction specialty care treatment program. Participants 79 (68% male) American Indian and Alaska Native (AI/AN) Tribal members meeting criteria for SUD and seeking SUD treatment. Interventions MICRA (individual therapy sessions beginning with MI for 2-3 sessions) compared with TAU (individual and group counseling sessions in a didactic style with Twelve-Step philosophy and elements of relapse prevention). Measures Demographics, percent days abstinent (PDA; the primary outcome at 12months assessed by Form 90D), Inventory of Drug Use Consequences, Alcohol and Drug Use Self-Efficacy Scale, Native American Spirituality Scale, and SCID-DSM-IV-TR. Findings There was no evidence for the benefit of MICRA over TAU (MICRA PDA = 72.63%, TAU = 73.62%, treatment effect: B = -4.04 (SE = 5.47); 95% CI = -14.941, 6.866; BF = 3.44) in the primary outcome. Both groups showed improvements in PDA, SUD severity, and negative consequences from baseline to the 12-month follow-up. Neither self-efficacy nor spirituality were significant mediators of MICRA. Conclusions There were no treatment group differences between culturally tailored evidence-based treatments for substance use disorder and treatment as usual in this randomized controlled trial with American Indian and Alaska Native participants. Nonetheless, participants improved over time on several substance-related outcomes.

Objective:To explore stakeholder perspectives regarding online diabetes nutrition education for American Indians and Alaska Natives (AI/AN) with type 2 diabetes (T2D).Design:Qualitative data were collected through focus groups and interviews. Focus group participants completed a brief demographic and internet use survey.Setting:Focus groups and community participant interviews were conducted in diverse AI/AN communities. Interviews with nationally recognised content experts were held via teleconference.Participants:Eight focus groups were conducted with AI/AN adults with T2D (n 29) and their family members (n 22). Community participant interviews were conducted with eleven clinicians and healthcare administrators working in Native communities. Interviews with nine content experts included clinicians and researchers serving AI/AN.Results:Qualitative content analysis used constant comparative method for coding and generating themes across transcripts. Descriptive statistics were computed from surveys. AI/AN adults access the internet primarily through smartphones, use the internet for many purposes and identify opportunities for online diabetes nutrition education.Conclusions:Online diabetes nutrition education may be feasible in Indian Country. These findings will inform the development of an eLearning diabetes nutrition education programme for AI/AN adults with T2D.

Limited research on elder abuse among American Indians and Alaska Natives (AIANs) suggests a higher prevalence of abuse. Using data from the National Elder Mistreatment Study (NEMS), we compared contextual characteristics and elder mistreatment prevalence rates from a community-based sample of AIAN ( n = 195) and Black ( n = 437) and White ( n = 5,013) respondents. There were differences in the prevalence of 16 abuse types and the 23 contextual variables. AIAN respondents had more similarities compared with Black respondents than White respondents, though differences existed. The cumulative prevalence of emotional, physical, and sexual mistreatment in the past year, neglect, and financial abuse by a family member for the AIAN group was 33%, almost double the 17.1% reported in the NEMS study. Over their lifetime, 29.7% of AIAN respondents reported experiencing two or more types of neglect, exploitation, or mistreatment. Almost one fourth of AIAN respondents reported emotional abuse since 60 years of age (the most commonly occurring abuse type)—nearly double that of White respondents. This is the first study to offer comparative prevalence of elder abuse for both AIAN older males and females that draws from a nationally representative sample. The study also provides descriptive analysis of important contextual information within the AIAN population, an underrepresented racial group in elder abuse research. Disaggregating nonmajority racial groups to examine contextual variables and the prevalence of elder mistreatment in the NEMS data set specific to AIAN respondents fills a knowledge gap. Known prevalence of various abuse typologies among AIAN elders can be useful in setting priorities for community planning and response, and in prioritization of funding for future research on causative mechanisms by abuse type, screening, and interventions at various levels. Findings may facilitate development of culturally specific evidence-based prevention and intervention practices aimed at needs specific to AIAN older adults.

Skin conditions affect an estimated 1.9 billion people worldwide. A shortage of dermatologists causes long wait times and leads patients to seek dermatologic care from general practitioners. However, the diagnostic accuracy of general practitioners has been reported to be only 0.24-0.70 (compared to 0.77-0.96 for dermatologists), resulting in referral errors, delays in care, and errors in diagnosis and treatment. In this paper, we developed a deep learning system (DLS) to provide a differential diagnosis of skin conditions for clinical cases (skin photographs and associated medical histories). The DLS distinguishes between 26 skin conditions that represent roughly 80% of the volume of skin conditions seen in primary care. The DLS was developed and validated using de-identified cases from a teledermatology practice serving 17 clinical sites via a temporal split: the first 14,021 cases for development and the last 3,756 cases for validation. On the validation set, where a panel of three board-certified dermatologists defined the reference standard for every case, the DLS achieved 0.71 and 0.93 top-1 and top-3 accuracies respectively. For a random subset of the validation set (n=963 cases), 18 clinicians reviewed the cases for comparison. On this subset, the DLS achieved a 0.67 top-1 accuracy, non-inferior to board-certified dermatologists (0.63, p

This study aimed to evaluate the effectiveness of an educational intervention at improving Oral Health Professionals (OHP's) knowledge of HPV and comfortability to discuss vaccination with their American Indian and Alaskan Native patients. OHP's attended an educational lecture covering HPV vaccination. Participants completed four validated questionnaires that encompassed a sociodemographic survey, a pre-lecture questionnaire (pre-Q), a post-lecture questionnaire (post-Q), and a follow-up questionnaire (follow-Q). The McNemar test was used to assess the significance of marginal probabilities in the responses between the pre-Q and post-Q and the Chi-square test to assess responses between the post-Q and follow-Q. A total of 122 OHP's completed the sociodemographic survey, pre-Q, and post-Q. Among these, 29 OHP's completed the eight-week follow-Q. The majority of all the participants were White/Caucasian (41%), 31 to 60years of age (72%), females (64%), and held a graduate/professional degree (52%). Analysis of the pre-Q responses showed that only 6.8% of OHP's discuss the connection between HPV and oropharyngeal cancer with patients and a lack of information on the topic was the major barrier reported. After the educational intervention (post-Q), 86.5% of OHP's reported they were more likely to recommend the HPV vaccine and 69.8% felt more comfortable administering it. Comparison between the pre-Q and the post-Q showed a significant improvement in overall HPV knowledge. Similarly, a comparison between the post-Q and the follow-Q showed retained knowledge overtime. Our study suggests that the educational intervention was effective at improving OHP's knowledge of HPV and enhancing their comfortability and preparedness to discuss the vaccination with their patients.

Following increases in reported cases of hepatitis A, we assessed the impact of hepatitis A vaccine in Alaska Native persons. During 1996–2018, only 6 cases of hepatitis A were identified, all in unvaccinated adults. Populations can be protected against hepatitis A by achieving sufficient vaccination coverage over time.

Background American Indian/Alaska Native (AI/AN) adolescents are at higher risk for gestational diabetes (GDM), type 2 diabetes, and pregnancy complications than the general population. Objective To inform cultural adaptation of a validated evidence-based intervention (VEBI) originally designed to deliver preconception counseling and diabetes education to non-AI/AN teens with diabetes. Design Qualitative data were collected using focus group and individual interview methods with health care professionals and experts (n = 16) in AI/AN health, GDM, adolescent health, and/or mother-daughter communication. A semistructured discussion guide elicited responses about provision of care for AI/AN girls at risk for GDM, experience with successful programs for AI/AN teens, comfort of mother/daughter dyads in talking about diabetes and reproductive health and reactions to video clips and booklet selections from the VEBI. All interviews were recorded and transcribed verbatim, and data analysis included inductive coding and identification of emergent themes. Results Providers felt teens and their moms would be comfortable talking about the VEBI topics and that teens who did not feel comfortable talking to their mom would likely rely on another adult female. Participants suggested including: AI/AN images/motifs, education with a community focus, and avoiding directive language. Concerns included: socioeconomic issues that affect AI/AN people such as: food and housing insecurity, abuse, and historical trauma. Conclusions Perspectives from these participants have been used to guide the development of a culturally tailored GDM risk reduction program for AI/AN girls. This program will be available to health care providers who serve the AI/AN population.

The purpose of this study was to explore (a) current utilization rates of university mental health services among American Indian/Alaskan Native/Native Hawaiian (AI/AN/NH) student veterans and (b) predictors of mental health service utilization among AI/AN student veterans.

Background Community advisory boards (CABs) are a common community engagement strategy. Tools for developing CABs that are accessible to academic-community partnerships are limited. This article describes the process and partnership with the Hopi Tribe to develop CAB guidelines as a tool for research funded by the Center for Indigenous Environmental Health Research (CIEHR) and nonaffiliated projects. Methods The CAB guidelines consist of three sections: formation, operation, and sustainability and evaluation. Each section includes best practices and interactive worksheets. The CAB guidelines were piloted with the Hopi Tribe to determine feasibility and relevance. Results The CAB guidelines were well-received by the tribal CAB. Some of the worksheets were difficult to complete because they did not represent their perspectives or introduced potential tension in CAB interactions. Revisions were made accordingly. Conclusions Future evaluation and broad dissemination of the CAB guidelines will promote the use and effectiveness of CABs in health research.

American Indian and Alaska Native (AI/AN) youth disproportionately face barriers accessing healthcare, including lack of access to culturally-specific resources. This paper details the creation of a culturally-specific Toolkit for AI/AN transgender and Two-Spirit youth, their relatives, and their healthcare providers across the United States (U.S.). The Toolkit aims to (1) deliver culturally-grounded resources to youth with diverse gender identities, (2) provide resources for families, and (3) increase healthcare provider awareness. A culturally-appropriate Toolkit, “Celebrating Our Magic”, was created from continual engagement with community partners over a six-month period to address identified needs. The Toolkit has been shared regionally with partners who helped with its creation and nationally with Indian Health Service (IHS), Tribal, and Urban clinics serving AI/AN youth. This Toolkit creation process could be applied to manuals or guides for work in other underserved communities.

BACKGROUND Among American Indians/Alaskan Natives (AI/ANs), suicides are disproportionately high among those younger than 40 years of age. This paper examines suicide and alcohol intoxication (postmortem BAC ≥ 0.08 g/dl) by age among Whites and AI/ANs to better understand the reasons for the high rate of suicide among AI/ANs for those younger than 40. METHODS Data come from the restricted 2003 to 2016 National Violent Death Reporting System (NVDRS), with postmortem information on 79,150 White and AI/AN suicide decedents of both genders who had a BAC test in 32 states of the United States. RESULTS Among Whites, 39.3% of decedents legally intoxicated are younger than 40 years of age, while among AI/ANs the proportion is 72.9% (p

INTRODUCTION Congenital anomalies were the leading cause of infant mortality, responsible for 23 and 21% of deaths in Oklahoma and the USA, respectively, in 2016. We aimed to determine the prevalence by race/ethnicity and spatial distribution of congenital anomalies to identify geographic and racial/ethnic disparities, particularly among American Indian/Alaska Natives (AI/AN). METHODS We evaluated the prevalence of anomalies by type and race/ethnicity among 648,074 live births in Oklahoma from 1997 to 2009. Prevalence proportion ratios (PPRs) and 95% confidence intervals (CIs) were calculated using Poisson regression. We used Moran's I and Getis-Ord Gi* to evaluate spatial clustering for neural tube defects, critical congenital heart defects (CCHDs), and oral clefts among births whose residence geocoded to the ZIP code or finer level. RESULTS Overall prevalence of anomalies among live births was 3.9%. Non-Hispanic (NH) African American (PPR: 0.87, 95% CI: 0.83, 0.91), Asian/Pacific Islander (PPR: 0.70, 95% CI: 0.63, 0.78), and Hispanic (PPR: 0.87, 95% CI: 0.83, 0.91) children had a lower prevalence of anomalies compared to NH whites. The prevalence in NH AI/AN children was similar to NH whites (PPR: 1.01, 95% CI: 0.97, 1.05). However, differences in specific types of anomalies were observed by race/ethnicity. We observed no spatial autocorrelation for CCHD and oral clefts. Neural tube defects demonstrated spatial autocorrelation (p

Currently, little is known about patterns of co-occurring risk and protective factors among young children. Understanding variations in co-occurring risk and protective factors among children in Alaska is important as experiences of collective trauma may contribute to differences in the intersection of risk and protective factors between Alaska Native/American Indian (AN/AI) and non-Native children. Using data from the Alaska Longitudinal Child Abuse and Neglect Linkage (ALCANLink) project, a linkage of the 2009–2011 Alaska Pregnancy Risk Assessment Monitoring System survey and administrative data sources, and the 2012–2014 Childhood Understanding Behaviors Survey, we conducted latent class analysis to identify classes of AN/AI (N=593) and non-Native (N=1,018) children in terms of seven risk factors (poverty, maternal depression, maternal binge drinking, parental incarceration, intimate partner violence exposure, other violence exposure, child maltreatment) and four protective factors (father figure involvement, reading by adults, family meals, peer interactions) experienced prior to age three years. We identified two classes among AN/AI children: 1) high risk-moderate protection (29.1%) and 2) low socioeconomic status-high protection (70.9%). We identified two classes among non-Native children: 1) moderate risk-high protection (32.9%) and 2) low risk-high protection (67.1%). A test of invariance revealed that risk and protective factor probabilities differed significantly for corresponding classes of AN/AI and non-Native children. Overall, results demonstrate heterogeneity within and between AN/AI and non-Native children in early experiences of risk and protection and suggest that interventions will be more effective if tailored to the experiences and developmental needs of specific demographic groups of Alaska children.

While smoking prevalence may be declining in the general population, health disparities in tobacco use remain a public health priority. This study examined national, sociodemographic, and geographic trends in American Indians and Alaska Natives (AIs/ANs) smoking prevalence from 1992/1993 to 2014/2015. Additionally, correlates of cigarette smoking were examined among this group. Data were drawn from the 1992–2015 Tobacco Use Supplement to the Current Population Survey. Cochran–Armitage tests were used to assess changes in the prevalence of smoking over time in the population, as well by sociodemographic characteristics. Multivariable logistic regression was conducted to examine the correlates of cigarette smoking for AIs/ANs in 2014/2015. The trend analysis indicated that the prevalence of smoking, among AIs/ANs, decreased significantly from 39.1% in the 1992/1993 cycle to 20.9% in the 2014/2015. This decrease was seen in both males and females, with the prevalence of smoking decreasing from 43.6% and 35.4%, respectively, in 2006/2007 to 23.8% and 18.3% in 2014/2015. The decreasing trend was also found for all subgroups, except for the 55+ age group. Multivariable analysis showed higher odds of smoking among males, those with low income compared to those with median or higher income, and those living in non-metropolitan areas. Those aged 25–54 were more likely to be smokers compared with the 55+ age group. Results indicate a recent decrease in AIs/ANs smoking prevalence, although these populations still experience a high prevalence of smoking compared to the general population. Our findings highlight the need for a comprehensive tobacco control strategy that includes working with stakeholders within the AI/AN community.

Youth homelessness is a serious national challenge affecting millions of young people every year. However, due to their relatively small population size, together with limitations related to data and research efforts on homelessness to date, prevalence estimates and evidence of homelessness experiences among American Indian and Alaska Native (AIAN) youth have been scarce. This is particularly the case at the national level. We report findings on the prevalence, characteristics, and correlates of AIAN youth experiencing homelessness that are based on a nationally representative survey on homelessness among adolescents and young adults, age 13 to 25. The overall national survey sample included 25,492 respondents. During a 12-month period, approximately 10.2% of AIAN households with 13-17 year olds reported youth homelessness or runaway experiences that lasted at least one night. For AIAN 18-25 year olds, the 12-month population prevalence of homelessness experiences was 12.2%. AIAN young adults had three times the prevalence rate of homelessness as their White non-Hispanic peers. Furthermore, most AIAN youth experiencing homelessness, like most AIAN people overall, reside in predominantly urban counties. Controlling for other variables, lower educational attainment, and parenting (especially if unmarried) were associated with higher likelihood of homelessness. There is a clear and urgent need for tailored, culturally-responsive homelessness prevention and intervention strategies, along with focused housing and support investments, for AIAN young people and the communities in which they live. The federal government and local jurisdictions need to take policy actions to address high rates of AIAN youth homelessness in urban and suburban communities, in addition to policies centered on AIAN reservations and rural communities.

Objectives The primary objective of this study was to work with tribal communities to define and develop their own healthcare services and strategies for positive change regarding injection drug use, human immunodeficiency virus (HIV), and hepatitis C virus (HCV) infection. The secondary objective of this study was to incorporate community capacity building strategies to develop and sustain programming and resources to optimize tribal communities’ responsiveness to reduce health disparities. Study design Semi-structured qualitative interviews. Methods Interviews were guided by community-based participatory research (CBPR) principles to create programs, projects, and policy recommendations meaningful to American Indian and Alaska Native (AI/AN) people. Results The study generated a formative understanding of the context of AI/AN people who inject drugs (PWID) in three distinct AI/AN communities as well as developed local capacity for future programming, projects, and policy. Conclusions This study confirms CBPR methods should be part of an iterative cycle to inform policy and programs. CBPR has helped strengthen local research capacity and has formed ongoing relationships between study investigators, local liaisons, and the community that will be essential for next phases of program design and policy implementation. This cycle of CBPR could be replicated in other tribal communities to bring awareness of the opioid epidemic and its effects and to prioritize local indigenous and community-led responses.

Background Certain research principles, framed within an indigenous context, are helpful guideposts to practice ethical, relevant, and sensitive inquiries. It is essential to further adapt research approaches based on the unique geographical, sociopolitical, and cultural attributes of partnering tribal communities. These adaptations are largely shaped by trial and error. Objectives The purpose of this article is to offer the prospective novice nurse researcher lessons that we learned when entering Indian country to conduct research for the first time. As indigenous and nonindigenous researchers, we are not seeking to set down a methodology but rather offer a list of processes, environments, timelines, and barriers that we never learned in didactic, seminar, clinical, practicum, or any other academic setting. Methods We organized a set of memories and thoughts through a series of semistructured iterative sessions specific to our first encounters as researchers in Indian country. We compiled our written responses and field notes from our dialogue, interpreted these data, and organized them into themes. We have reported what we felt would be the most surprising, frequent, or important information to note. Results We identified three overarching themes in our collective experience: orientation and negotiation, situating ourselves and our work, and navigating our way. Subthemes included perceiving ourselves as outsiders, negotiating distance and time realities, relying on the goodness of gatekeepers, shaping research questions per community priorities, honing our cross-cultural and intercultural communication skills, discovering the many layers of tribal approval processes, and developing sensibilities and intuition. Discussion Our previous experiences as novices leading research projects in Indian country have produced unique sensibilities that may serve to guide nurse researchers who seek to partner with tribal communities.

Background Although colorectal cancer occurs earlier in life and at twice the frequency in Alaska Native (AN) people compared with the general population, the colorectal polyp burden in this group has not been quantified. In addition, an appropriate age for initial screening in ANs has not been defined. Materials and methods A retrospective chart review of 766 AN people who had screening colonoscopy from 2015 to 2016 was performed. The polyp burden in patients aged 40-49 y was compared with that in those aged 50-59 y in both the AN and the general US populations. Results In total, 345 adenomas were removed: 121 (35%) from 40- to 49-year-olds and 224 (65%) from 50- to 59-year-olds. Twenty-six percent of AN people aged 40 y to 49 y and 40% of AN people aged 50 to 59 y had at least one adenoma. Low- and high-risk adenomas were significantly less frequent in the younger group (22% versus 29%, P = 0.048; 9.2% versus 15%, P = 0.035; respectively). Advanced adenomas were also less frequent in the younger group, although not statistically significant. Polyp histology, size, location, and morphology did not differ significantly between groups. Conclusions The adenoma and advanced adenoma prevalence in 40- to 49-year-old AN people is high, suggesting colorectal cancer screening should begin at age 40 y in ANs.

We provide a literature review concerning healthcare access for Native Americans in rural areas. We group previous research around three themes; barriers in rural America; barriers within the Indian Health Services system (including provider recruitment and retention); and the scale of services offered. Considering a wide range of access measures, a general failure exists in providing Native Americans with services comparable to those received by other Americans There are repeated findings of disparities in specific resources available, such as staff and infrastructure. Improvement appears possible through increased funding, and by giving greater management control to each tribe.

Genomic research raises unique ethical concerns among Alaska Native and American Indian (AN/AI) people and their communities. The Center for the Ethics of Indigenous Genomic Research (CEIGR) was created to foster research that takes these concerns into account while considering the sovereign status of AN/AI tribal nations. Relationships developed within CEIGR have allowed for effective, collaborative research among individuals who come from diverse cultures, political and historical backgrounds, and academic disciplines, and who work for organizations with varying resources, capacities, and expectations. The CEIGR framework may inform other groups seeking to conduct social science research related to genomic research with tribal people and their communities.

Alaska Native (AN) people have among the highest rates of colorectal cancer (CRC) recorded globally. Preventing CRC is an important health priority of AN tribal health leaders and communities. Lifestyle and genetic risk and protective factors for CRC among AN people remain understudied. We have been working to establish a tribally led, community-based, comprehensive investigation of lifestyle and genetic risk and protective factors for CRC among AN people. We describe the process of initiating this research study, including conversations with key tribal health system staff. We discuss themes that arose during these conversations and literature review and describe how those themes were used during the study design and protocol development phase. This description is intended to provide guidance to other researchers working to establish community-based studies of cancer risk, particularly among tribal communities.

We systematically reviewed the literature on risk factors for obesity in American Indians (AIs) and Alaska Natives (ANs) of all ages.We searched titles and abstracts in PubMed with combinations of the following terms: obesity, body mass index (BMI), American Indian, Alaska Native, and Native American.We limited our review to articles that provided an empirically testable claim about a variable associated with obesity, measured obesity as a dependent variable, and provided data specific to AI/ANs.Our final sample included 31 articles; 20 examined AI/AN youth (18 years), and 11 examined AI/AN adults (≥18 years). Risk factors for obesity varied by age. In infants, low birth weight, early termination of breastfeeding, and high maternal BMI, and maternal diabetes increased the risk of childhood obesity. In children and adolescents, parental obesity, sedentary behaviors, and limited access to fruits and vegetables were associated with obesity. In adulthood, sedentary behaviors, diets high in fats and carbohydrates, stress, verbal abuse in childhood, and the belief that health cannot be controlled were associated with obesity.Extant studies have three limitations: they do not apply a life course perspective, they lack nationally representative data and have limited knowledge of the resilience, resistance and resourcefulness of AI/ANs. Future studies that avoid these shortcomings are needed to inform interventions to reduce the prevalence of obesity in AI/ANs across the life course.

Introduction American Indian/Alaska Native (AI/AN) youth are more likely to smoke than non-Native youth. The aim of this study is to compare tobacco product use among youth by AI/AN race and region over time to identify populations and geographies of higher risk. Methods From 2015 to 2018, biennial U.S. Youth Risk Behavior Surveillance data from 29 states were examined to compare ever and current cigarette use, current cigar use, current smokeless tobacco use, and cigarette initiation before the age of 13 years between non-Hispanic AI/AN and non-Native youth by region from 2007 to 2013. Results Although cigarette use among AI/AN and non-Native youth decreased significantly from 2007 to 2013, AI/AN youth were significantly more likely than non-Native youth to ever use (AOR=1.88, 95% CI=1.71, 2.06) or currently use (AOR=1.88, 95% CI=1.69, 2.09) cigarettes, currently use cigars (AOR=1.17, 95% CI=1.03, 1.34), currently use smokeless tobacco (AOR=1.84, 95% CI=1.63, 2.07), or initiate cigarette use before the age of 13 years (AOR=1.92, 95% CI=1.72, 2.15). Disparities between AI/AN and non-Native youth varied by region, with the largest disparity in Northern Plains and Alaska. Conclusions The prevalence of AI/AN youth cigarette, cigar, and smokeless tobacco use is significantly higher than that of non-Native youth. Tobacco control efforts to address AI/AN cigarette use disparities may consider those younger than 13 years.

OBJECTIVES: This study assessed the associations between short and long sleep duration and prevalence of cardiometabolic outcomes in American Indians and Alaska Natives (AI/ANs) and compared these associations to those evident among other race/ethnicities. METHODS: We analyzed data from the 2013-2014 Behavioral Risk Factor Surveillance System. In total, 14,536 AI/ANs, 729,962 non-Hispanic whites, 71,765 blacks, and 59,472 Hispanics were included. Logistic regressions were conducted to compute unadjusted and adjusted odds ratios (OR) for the associations of interest. RESULTS: Among AI/ANs, 38.6% reported sleeping

L'activite physique est generalement consideree comme un facteur contribuant de facon significative au vieillissement reussi d'une personne. Certains groupes n'ont cependant pas ete suffisamment representes dans les discussions sur l'activite physique et le vieillissement, particulierement ceux provenant d'horizons culturels differents. Dans cet article, nous explorons comment les aines autochtones de l'Alaska percoivent le role de l'activite physique au cours de leur vieillissement et la contribution de l'activite physique au vieillissement reussi. Les entretiens semi-structures menes aupres de 41 aines ont montre que l'activite physique n'etait pas seulement percue comme une responsabilite personnelle en vue du maintien d'une bonne sante lors du vieillissement, mais aussi comme un moyen de resister a l'opinion repandue voulant que les personnes âgees soient dans une phase de declin. Pour ces aines, etre physiquement actif, peu importe l'âge, etait vu comme un moyen pour ameliorer ou maintenir leur etat physique, mental, emotionnel ou spirituel, et permettrait de participer aux activites de subsistance qui sont rattachees a leur culture et aux roles ancestraux qui leur sont reconnus. Physical activity is widely considered to be a significant contributing factor to how “successfully” one ages. There are, however, certain groups whose voices have not been widely heard in discussions around physical activity and aging, particularly those from diverse cultural backgrounds. In this research, we explored how Alaska Native Elders perceive the role of physical activity as they age and its contribution to successful aging. Based on semi-structured interviews with 41 Elders, the results show that engaging in physical activity was not just seen as a personal responsibility to maintain health and age successfully, but also as a way to resist Western society’s dominant view of older adults as deteriorating and declining by being physically active regardless of age; to improve or maintain their physical, mental, emotional, and spiritual health; and/or to enable them to continue participating in subsistence activities that are rooted in their culture and traditional roles as Elders.

Background The goal of adaptation is to maintain the effectiveness of the original intervention by preserving the core elements that account for its success while delivering an intervention that is tailored to the new community and/or cultural context. The current study describes the process of adapting an evidence-based smoke-free homes (SFH) intervention for use in American Indian/Alaska Native (AI/AN) households. Methods We followed a systematic adaptation process. We first assessed the community through focus groups coordinated in collaboration with tribal partners. Because our team included the original developers of the intervention, the steps of understanding the intervention, selecting the intervention and consulting with experts were simplified. Additional steps included consulting with stakeholders through a national work group and collaboratively deciding what needed adaptation. Results A number of key themes pertinent to the adaptation of the SFH intervention were identified in the focus groups. These included the gravity of messaging about commercial tobacco use; respect, familialism, and intergenerationalism; imagery, including significant symbolism, colors, and representative role models; whether and how to address traditional tobacco; and, barriers to a SFH not adequately addressed in the original materials. Conclusions Adaptation of an intervention to create smoke-free homes in AI/AN families necessitated both surface structure changes such as appearance of role models and deep structure changes that addressed core values, and beliefs and traditions. Electronic supplementary material The online version of this article (10.1186/s12889-019-7301-4) contains supplementary material, which is available to authorized users.

Objective: To compare adherence one year before and after blister pack implementation in America Indian and Alaska Native (AI/AN) patients and to describe the patient population who used blister packs in the outpatient setting. Methods: A retrospective analysis of AI/AN patients receiving blister packs was performed to determine medication adherence as measured by a variable medication possession ratio (MPR). Patient characteristics and the reason for blister pack initiation were also assessed. Results: Of the 25 patients receiving blister packs, 76% were female, 56% were elderly and 60% had cognitive impairment. The three most common types of medications used were hypertension meds, vitamins and diabetes meds. The average MPR one year before blister pack implementation was 67.4% and significantly increased to 86.0% one year after. Conclusion: Blister packs significantly increased the average MPR after one year of implementation in a small group of AI/AN patients. Blister packs were utilized most commonly in patients who were female, had cognitive impairment, and who were taking numerous medications with a high pill burden in the outpatient setting.