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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: Suicide is the second leading cause of death for Native youth aged 15-24. Similarly, Native youth have a suicide rate 1.5 times higher than the general population and are at higher risk for depression and substance use. A persistent need remains for culturally specific mental health interventions for American Indian youth.Methods: In response to the push for research-supported interventions, evidence mapping has emerged as systematic, rigorous, and replicable analysis of evidence. The overall goal of this study is to utilize evidence mapping for mental health interventions for American Indian youth.Results: A total of 9 interventions were mapped as research-supported interventions for American Indian mental health. The interventions fell into one or more of four main categories: school-based services, cultural adaptations, culture as treatment, and community involvement.Discussion: Results of this study demonstrate the strength of culturally specific mental health interventions for American Indian youth. Future research should seek to evaluate promising practices for American Indian youth in order to increase available research-supported interventions. Additionally, future endeavors should seek to combine both Indigenous and Western approaches to practice with a particular focus on holistic wellness.

This study reviews student's perspectives of an American Indian and Alaska Native Indian Studies center in a Master of Social Work degree (MSW) program from the Brown School at Washington University in St. Louis. The article describes the Kathryn M. Buder Center for American Indian Studies many contributions over the years and how it continues to grow in innovative ways. This article begins by considering the social, economic, and historical circumstances that make Native-focused training in social work critical to the future of Indian Country. The article then discusses the founding of the center, the curriculum, program offerings and the effectiveness of the center's services. Additionally, results of the evidence indicates that financial assistance and support programs are strong factors in recruitment, student motivation to pursue a degree, and persistence to completion of a Master of Social Work credential. Lastly, the paper offers recommendations for recruiting, retaining and graduating American Indian and Alaska Native graduate students.

Introduction: Many barriers exist for American Indian/Alaska Native (AI/AN) students pursuing advanced degrees. The Brown School at Washington University in St. Louis has a higher than aver...

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.

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

Background Although a community-based participatory research (CBPR) approach is desired by American Indian/Alaska Native (AI/AN) tribes, many researchers and tribes experience challenges in research partnerships. The aim of this project was to develop and disseminate an evidence-based training toolkit to help strengthen tribal-academic research partnerships. Our prior research found that governance, trust, and culture were essential pillars for successful community academic partnerships. Methods This article describes the development and evaluation of the new Holding Space: A Guide for Partners in Tribal Research toolkit, which contains a Holding Space Discussion Guide and the Tribal Research Future Game, which are delivered in a training format for participants in tribal- academic research partnerships. Results Results indicate that Holding Space is a useful tool for facilitating conversations and openly reflecting on practices within partnerships and may also be appropriate for a broader audience. Conclusions Future work includes further effectiveness studies as well as research focused on dissemination and implementation.

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.

United States Consumer Product Safety Commission (CPSC) reported a 700% increase in Emergency Department (ED) visits for injuries attributed to unpowered scooter use from January through October 2000. Our objective is to investigate injuries associated with the use of unpowered scooters among adolescents from the age of >9 years to 20 years in the National Electronic Injury Surveillance Study (NEISS) data set from 2007-2017. We analyzed unpowered scooter-related injuries in the NEISS data set using variables: SCOOTER, INJURED, AFTER, OFF, AT and IN; the product code for injuries related to unpowered scooters is 1329, and age ≥9 years and 9 - 19

Background The Alaska Native Community Resilience Study (ANCRS) is the central research project of the Alaska Native Collaborative Hub for Research on Resilience (ANCHRR), one of three American Indian and Alaska Native (AIAN) suicide prevention hubs funded by the National Institute of Mental Health. Objective This paper describes the development of a structured interview to identify and measure community-level protective factors that may reduce suicide risk among youth in rural Alaska Native communities. Methods Multilevel, iterative collaborative processes resulted in: a) expanded and refined constructs of community-level protection, b) clearer and broadly relevant item wording, c) respectful data collection procedures, and d) Alaska Native people from rural Alaska as primary knowledge-gathering interviewers. Lessons learned Moving beyond engagement to knowledge co-production in Alaska Native research requires flexibility, shared decision-making and commitment to diverse knowledge systems; this can result in culturally attuned methods, greater tool validity, new ways to understand complex issues and innovations that support community health.

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

Introduction Despite progress, injury remains the leading cause of preventable death for American Indian and Alaska Natives (AI/AN), aged 1 to 44. There are few publications on injuries among the AI/AN population, especially those on traumatic brain injury (TBI). A TBI can cause short- or long-term changes in cognition, communication, and/or emotion. Methods: To describe changes over time in TBI incidence by mechanism of injury, injury intent, and age group among AI/ANs, the CDC analyzed hospitalization and death data from the 2008–2014 Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) and the National Vital Statistics System (NVSS), respectively. Results: From 2008-2014, the incidence of TBI-related hospitalizations increased by 32% (1,477 in 2008 to 1,945 in 2014) and resulted in a 21% increase in age-adjusted rates of people hospitalized with TBI. TBI-related deaths increased in number (569 in 2008 to 644 in 2014) and age-adjusted rate (22.7 in 2008 to 25.4 in 2014) by approximately 13% and 12%, respectively. Motor-vehicle crashes were the leading cause of TBI-related deaths among AI/ANs aged 0–54 years. Practical application: Prevention efforts should focus on increasing motor-vehicle safety and advancing prevention strategies for other leading causes of TBI, including: falls, intentional self-harm, and assaults.

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.

Objective Valid neuropsychological assessment is critical to the accurate diagnosis and effective treatment of diverse populations. American Indians and Alaska Natives experience substantial health disparities relative to the general U.S. Population Given the dearth of studies on neuropsychological health in this population, we aimed to characterize neuropsychological performance among older American Indians with respect to age, sex, education, income, and language use. Method From 2010 to 2014, we recruited 818 American Indians aged 60 and older from the Cerebrovascular Disease and Its Consequences in American Indians Study, who comprised all of the surviving members of a cardiovascular study (Strong Heart Study). This cohort from 11 tribes resided on or near their home reservations in three geographic regions (Northern Plains, Southern Plains, and Southwest). Using a cross-sectional design investigating potential vascular brain injury, we administered a brief, targeted neuropsychological and motor function assessments. Results Higher scores on neuropsychological tests were associated with younger age, female sex, more education, higher income, and less Native American language use. Similar associations were found for the motor tests, although men had higher scores on both motor function tests. After accounting for other sociocultural and health factors, age, sex, education, income, and Native American language use all had significant associations to the test scores. Conclusions Our findings may be used to guide research and inform clinical practice. The development of future normative studies for older American Indians will be more culturally appropriate when sociocultural factors are included. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

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.

Suicide is the second leading cause of death among American Indian and Alaska Native youth, and within the Alaska Native youth subpopulation, the leading cause of death. In response to this public health crisis, American Indian and Alaska Native communities have created strategies to protect their young people by building resilience using localized Indigenous well-being frameworks and cultural strengths. These approaches to suicide prevention emphasize promotion of protective factors over risk reduction. A measure of culturally based protective factors from suicide risk has potential to assess outcomes from these strengths-based, culturally grounded suicide prevention efforts, and can potentially address several substantive concerns regarding direct assessment of suicide risk. We report on the Reasons for Life (RFL) scale, a measure of protective factors from suicide, testing psychometric properties including internal structure with 302 rural Alaska Native Yup’ik youth. Confirmatory factor analyses revealed the RFL is best described through three distinct first-order factors organized under one higher second-order factor. Item response theory analyses identified 11 satisfactorily functioning items. The RFL correlates with other measures of more general protective factors. Implications of these findings are described, including generalizability to other American Indian and Alaska Native, other Indigenous, and other culturally distinct suicide disparities groups.

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.

Objectives: American Indians and Alaska Natives (AI/AN) have a unique healthcare system uniquely interwoven with the Affordable Care Act (ACA). The aim of this study is to document changes in healt...

Belief in an American Indian/Alaska Native (AI/AN) specific biological vulnerability (BV) to alcohol problems (aka the “firewater myth”) has been found to be associated with worse alcohol outcomes among AI/AN college students who drink, despite also being associated with greater attempts to reduce drinking. In the current study, we examined the associations of belief in a BV and belief that AI/AN people have more alcohol problems with the use of alcohol protective behavioral strategies (PBS) among AI/AN college students. PBS examined, as measured by the Protective Behavioral Strategies Scale-20, included manner of drinking, limiting/stopping drinking, and serious harm reduction strategies. Participants were college students who identified being AI/AN (n = 137) and had drank in the past month, and were selected from a larger multi-site study on PBS. Mediation models revealed that greater belief in a BV and belief that AI/AN people have more alcohol problems were both negatively associated with manner of drinking, which in turn was associated with greater past month alcohol use and alcohol consequences. These beliefs were not significantly associated with other PBS. Consistent with prior research with other student populations, both manner of drinking and limiting/stopping drinking were associated with less alcohol use and all three domains of PBS were directly associated with fewer alcohol consequences. The results suggest that these beliefs regarding AI/AN people and alcohol negatively affect the use of strategies aimed at avoiding drinking behavior that can lead to rapid drinking and a higher blood alcohol content, contributing to alcohol consequences.

Background Alaska Native children, including children of Yup'ik descent, consume large volumes of sugar-sweetened fruit drinks, which contain added sugars that contribute to obesity, diabetes, and dental caries. To date, taste preference evaluations have not been conducted on commercially available sugar-free fruit drinks. Objective The study tested the hypothesis that children would have equal preference for sugar-free and sugar-sweetened fruit drinks. Design This was an experimental two-alternative forced-choice paired preference test. Participants/setting The study focused on a convenience sample of Yup'ik children, aged 7 to 10 years, recruited and enrolled from the Yukon-Kuskokwim Health Corporation dental clinic in Bethel, AK (N=89). Intervention Children evaluated four different commercially available sugar-free fruit drinks paired with the sugar-sweetened versions of each flavor. Order of flavor pair presentation was alternated across children, and order of presentation within each of the four pairs was randomized across pairs. Main outcome measures The outcome was taste preference for the sugar-free versus the sugar-sweetened version of a fruit drink. Statistical analyses performed A test of equivalence was run across all four flavors and separately for each flavor using two one-sided tests. Results The data failed to demonstrate equivalence of the sugar-free and sugar-sweetened fruit drinks across all four flavors (P=0.51) or separately for each flavor. However, this was not because of a preference for sugar-sweetened drinks. The preference for sugar-free drinks overall and for each flavor was >50%. Although the lower bounds of the 90% CIs were within the range of equivalence (40% to 60%), the upper bounds were outside the range of equivalence (>60%). According to post hoc analyses, similar preferences were observed for Yup'ik and non-Yup'ik children, boys and girls, and children of different ages. Conclusions Taste preference findings suggest that sugar-free fruit drinks may be a well-tolerated alternative to sugar-sweetened fruit drinks for Yup'ik children in Alaska Native communities.

Health disparities have long affected American Indian and Alaska Native (AI/AN) populations. Transformations are needed in academia to help understand Indigenous 'ways of knowing.' Lifting the voices of AI/ANs in telling their stories could improve the education of students, faculty and the lay public. We collaborated to develop, implement and evaluate a Native American Health Seminar Series taught by AI/AN leaders on addressing health disparities among AI/AN people. A quasi-experimental mixed methods design included a 15-item survey to assess the impact of the Seminar Series on knowledge of AI/AN health issues and its influence, among students, on health career choices. During the 2018 academic year, three seminars were held and 243 participants attended. In total, 182 surveys (74.9%) were completed by faculty members, students and members of the lay public. Students (all categories combined) represented the highest participant group (48.4%), followed by the lay public at 30% and faculty at 21.6%. The highest scores on knowledge of Native health issues prior to seminar attendance were reported by those representing the lay public with a mean of 3.96 compared to 3.67 for faculty and 3.43 among students (p = 0.01), which was highly represented by Indigenous people. Increases in knowledge occurred in all participant groups. Among students, 65.6% initially indicated that they were not planning on pursuing a career in Native health. Among these, 56.9% indicated they were somewhat to extremely likely to pursue a career in Native health as a result of having attended the seminar.

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

Smoke-free homes can reduce exposure to secondhand smoke (SHS) and support smoking cessation. The current study seeks to understand perspectives, including barriers and facilitators, on smoke-free homes among five American Indian/Alaska Native (AI/AN) communities. Guided by a national work group of tribal partners, ten focus groups were conducted with AI/AN adult smokers and nonsmokers (n = 95) in Alaska, California, Michigan and Oklahoma, stratified by smoking status. The majority of participants lived in single unit detached homes (70.5%). Most of the nonsmokers had a smoke-free home rule (92.9%) and a majority of smokers did as well (64.7%). The most common reasons for smoke-free home rules were protecting children and grandchildren, including children with health problems. Challenges to a smoke-free home included weather and visitors who smoked, along with the inconvenience of going outside, the habit of smoking inside, the need to watch a young child, safety concerns, and smokers who break the rules. Respecting rules and respecting elders emerged as important themes. Traditional use of tobacco in the home was viewed as quite distinct from recreational or everyday use. Over half (58.2%) reported never using tobacco for ceremonial, prayer or traditional reasons in their homes. Given unique considerations for the adoption of smoke-free homes in AI/AN communities, particularly regarding the use of sacred tobacco for traditional, ceremonial, or medicinal purposes, it is important to learn which barriers and facilitators are similar to the general population and which may be unique to tribal communities in the U.S.

Objectives To evaluate a storytelling intervention targeting the oral health beliefs, knowledge, and behaviors of AIAN pregnant women and mothers. Methods Fifty-three adult AIAN women from three tribal communities in Northern California participated. The intervention story delivered oral health messaging using a traditional storytelling format. The effect of the intervention on self-reported oral health behaviors, dental knowledge, and beliefs was assessed using a pretest-posttest design, with an additional six-month follow-up. Tests of repeated measures using Generalized Linear Models were conducted to assess changes in oral health knowledge, beliefs, and behaviors. Results Knowledge and beliefs significantly increased as a result of the intervention and persisted after six months. A consistent, significant increase in positive oral health behaviors from baseline to six-months was also observed. Conclusions The results of this intervention study suggest promise for traditional storytelling to increase oral health-related knowledge, beliefs, and behaviors among self-identified AIAN pregnant women and mothers.

Objective: How social support (SS) affects the odds of suicide attempt among American Indian/Alaska Native (AI/AN) youth in New Mexico and is modified by school location and metropolitan status. Me...

Background Nonmedical use of prescription opioids (defined as taking opioid medications for hedonic effects or in a manner other than prescribed) and the use of heroin have emerged in recent years as major public health concerns in the United States. Of particular concern is the prevalence of opioid use among emerging adults (ages 18–25), as this is a developmental period of heightened vulnerability and critical social, neurological, and psychological development. Data from 2015 show that American Indian/Alaska Native (AI/AN) people have the highest rates of diagnosis for opioid use disorders (OUDs). One recent study found that the overdose death rate among urban-dwelling AI/AN individuals was 1.4 times higher compared to those living in rural areas. To date, there are no evidence-based prevention programs addressing opioid use among urban AI/AN emerging adults that integrate culturally-appropriate strategies with evidence-based treatment. Traditions and Connections for Urban Native Americans (TACUNA) builds on our prior work with AI/AN communities across California to develop and evaluate culturally appropriate programming to address opioid, alcohol, and cannabis use among urban AI/AN emerging adults. Methods/design In a randomized controlled trial, 18–25 year old urban AI/AN emerging adults will receive either TACUNA (n = 185), which comprises three virtual workshops utilizing motivational interviewing, social network visualization, and integrating traditional practices and a wellness circle, or one virtual culturally sensitive opioid education workshop (n = 185). We will evaluate intervention effects on primary outcomes of frequency of opioid, alcohol, and cannabis use, as well as secondary outcomes of social network characteristics and cultural connectedness, over a 12-month period. Discussion This project has the potential to expand the range and effectiveness of opioid, alcohol, and cannabis services for urban AI/AN emerging adults by addressing the opioid epidemic and use of other substances at both the community and individual level. In addition, it provides important culturally grounded conceptual and practical information to advance the field of substance use interventions and enhance resiliency among this population. Trial registration: ClinicalTrials.gov Identifier: NCT04617938. Registered October 26, 2020 https://clinicaltrials.gov/ct2/show/record/NCT04617938.

American Indian/Alaska Native (AI/AN) people have historically been excluded from eating disorder research. Consequently, not much is known about the validity of eating disorder assessment measures in this group. The purpose of the current study was to examine the factor structure of a short measure for eating pathology, the seven-item Eating Disorder Examination Questionnaire (EDE-Q7), in AI/AN undergraduate women. Exploratory analyses examined the measurement invariance of the EDE-Q7 across AI/AN, White, and Latinx undergraduates.A sample of 150 AI/AN undergraduate women completed the full EDE-Q (28 items) as part of two larger studies. The seven items comprising the EDE-Q7 were selected from the full measure to test the factor structure. Random samples of White and Latinx women of equal sample size were chosen from the larger studies to test measurement invariance.Confirmatory factor analyses found support for the EDE-Q7 factor structure in AI/AN undergraduate women, and scores were strongly positively correlated with the original EDE-Q global scale and disordered eating behaviors. Exploratory analyses found support for the measurement invariance of the EDE-Q7 across AI/AN, White, and Latinx women. One-way ANOVAs showed no significant racial and ethnic differences on the EDE-Q7.The current study found psychometric support for the EDE-Q7 in AI/AN undergraduate women and provided preliminary evidence that the EDE-Q7 can be meaningfully compared across AI/AN, White, and Latinx undergraduate women. Further research should continue to investigate the EDE-Q7 and other eating disorder measures in AI/AN and other historically excluded groups.V, cross-sectional descriptive study.

OBJECTIVE: The purpose of this study was to examine associations with high-intensity drinking (HID) in American Indian/Alaska Native (AI/AN) populations and compare them to White and other minority groups using four National Alcohol Surveys, 2000 to 2015 (total N = 29,571; AI/ANs = 434). METHOD: Current drinking and HID (8+ and 12+ drinks on any day) from maximum drinks in the prior 12 months were analyzed with independent variables and race/ethnicity (AI/AN, non-Hispanic White, and other racial/ethnic groups combined). Adjusted logistic regression models comprised gender, age, marital status, employment, education, survey year, rurality, and especially, childhood trauma (physical/sexual abuse), and biological family alcohol problem history (each dichotomous). RESULTS: In adjusted population models, Whites had twice the odds of current drinking as AI/ANs, with no difference between other racial/ethnic groups and AI/ANs. Descriptively, AI/AN drinkers consumed at higher intensity levels than other groups, with higher prevalence of childhood trauma and family problem drinking than others. However, on a population basis, adjusting for all factors, apparent differences between AI/AN and White HID were eliminated; other minority groups together, compared with AI/ANs, showed lower odds of consuming 8+ drinks. CONCLUSIONS: AI/ANs had a higher prevalence of childhood trauma and family alcohol problems as well as lower current drinking likelihood compared with Whites. In adjusted population models, the combined other minorities group was less likely to ever consume 8+ drinks than AI/ANs. In all populations, childhood trauma and family alcohol problems increased the risk of HID, strongly so in AI/ANs. Addressing childhood trauma and family problems is important among AI/ANs to break generational cycles of drinking extreme amounts per occasion.

We provide guidance for conducting clinical trials with Indigenous children in the United States. We drew on extant literature and our experience to describe 3 best practices for the ethical and effective conduct of clinical trials with Indigenous children. Case examples of pediatric research conducted with American Indian, Alaska Native, and Native Hawaiian communities are provided to illustrate these practices. Ethical and effective clinical trials with Indigenous children require early and sustained community engagement, building capacity for Indigenous research, and supporting community oversight and ownership of research. Effective engagement requires equity, trust, shared interests, and mutual benefit among partners over time. Capacity building should prioritize developing Indigenous researchers. Supporting community oversight and ownership of research means that investigators should plan for data-sharing agreements, return or destruction of data, and multiple regulatory approvals. Indigenous children must be included in clinical trials to reduce health disparities and improve health outcomes in these pediatric populations. Establishment of the Environmental Influences on Child Health Outcomes Institutional Development Award States Pediatric Clinical Trials Network (ECHO ISPCTN) in 2016 creates a unique and timely opportunity to increase Indigenous children’s participation in state-of-the-art clinical trials.

The American Indian and Alaska Native Head Start Family and Child Experiences Survey (AIAN FACES) 2015 was the first national study of children served by Region XI Head Start programs, which are those operated by federally recognized AIAN tribes. Until 2015, Region XI programs had not been included in national studies of Head Start children's experiences and development, leaving them without this critical source of data to inform policy and practice as is available to other Head Start regions. To address this gap, four groups of stakeholders gathered to plan for a study that put the needs of Region XI Head Start at the forefront, was informed by the historical context of research with AIAN communities, and was guided by community psychology and community-based and tribal participatory approaches. Engaged partnership is a common practice in research with AIAN communities, but rarely on a national scale across diverse communities. The study's success speaks to the success of the unique national partnership between the Region XI Head Start, research, and federal stakeholders who formed the AIAN FACES Workgroup. This first-person account documents the perspective of each group as they undertook this seminal effort and reviews connections with, and lessons learned for, the broader field of community psychology.

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

OBJECTIVE: To elicit feedback from tribal leaders and American Indian/Alaska Native (AI/AN) health system administrators as a national stakeholder perspective to inform the development of a gestational diabetes mellitus (GDM) risk reduction and preconception counseling intervention for AI/AN teenagers at high risk for GDM. METHODS: A semi-structured focus group interview guide was developed by both principal investigators and qualitative methods experts. Using open-ended questions about the Reproductive-health Education and Awareness of Diabetes in Youth for Girls (READY-Girls) booklet and video clips, AI/AN health care system administrators and elected tribal leaders attending the 2015 National Indian Health Board Conference in Washington, DC, made recommendations on adaptation for an AI/AN audience. The focus group was recorded, transcribed verbatim, and analyzed by two researchers using an inductive coding technique with constant comparison method as supported by the grounded theory approach. RESULTS: Recommendations from the 12 participants included: (1) the best ways to communicate with AI/AN teenagers, (2) the importance of parental, family, and community education and engagement to support AI/AN teenagers in GDM risk reduction, and (3) building on traditional AI/AN cultural values and practices, while accommodating differences between tribes and regions. CONCLUSION: Findings from this focus group were used to inform the iterative development of a GDM risk reduction and preconception counseling intervention for AI/AN teenagers.

Background: The American Indian/Alaskan Native (AI/AN) mortality rate from illicit drug use was 22.7%, double that of the general population between 2007 and 2009. Fifteen percent of AI/AN youth reported receiving treatment for substance use compared with 10% of non-AI/AN peers. Objective: The purpose was to explore the factors that influence substance use among AI/AN youth. Method: We performed a systematic review using a results-based convergent synthesis design. Eight electronic databases were searched for articles published between 2014 and 2019 using the search terms “Native American youth,” “Native American adolescent,” “Native Youth,” “substance use,” “substance misuse,” and “substance abuse.” The Mixed Methods Appraisal Tool was used to appraise the studies. Results: Forty-seven studies met the inclusion criteria (44 quantitative, one qualitative, and two mixed-methods studies). The results were organized using the ecological systems model and included evaluation of both protective and risk factors related to AI/AN youth substance use. Three system levels were found to influence substance use: individual, micro- and macrosystems. The individual systems-level coping mechanisms played a key role in whether AI/AN youth initiated substance use. Family, school, and peer factors influence the microsystem level. At the macrosystem level, community environmental factors were influential. Conclusion: The major factor linking all the systems was the influence of a connected relationship with a prosocial adult who instilled future aspirations and a positive cultural identity. Findings of this systematic mixed studies review will assist in intervention development for AI/AN youth to prevent substance misuse.

IntroductionDiet, shown to impact colorectal cancer (CRC) risk, is a modifiable environmental factor. Fibre foods fermented by gut microbiota produce metabolites that not only provide food for the colonic epithelium but also exert regulatory effects on colonic mucosal inflammation and proliferation. We describe methods used in a double-blinded, randomised, controlled trial with Alaska Native (AN) people to determine if dietary fibre supplementation can substantially reduce CRC risk among people with the highest reported CRC incidence worldwide.Methods and analysesEligible patients undergoing routine screening colonoscopy consent to baseline assessments and specimen/data collection (blood, urine, stool, saliva, breath and colon mucosal biopsies) at the time of colonoscopy. Following an 8-week stabilisation period to re-establish normal gut microbiota post colonoscopy, study personnel randomise participants to either a high fibre supplement (resistant starch, n=30) or placebo (digestible starch, n=30) condition, repeating stool sample collection. During the 28-day supplement trial, each participant consumes their usual diet plus their supplement under direct observation. On day 29, participants undergo a flexible sigmoidoscopy to obtain mucosal biopsy samples to measure the effect of the supplement on inflammatory and proliferative biomarkers of cancer risk, with follow-up assessments and data/specimen collection similar to baseline. Secondary outcome measures include the impact of a high fibre supplement on the oral and colonic microbiome and biofluid metabolome.Ethics and disseminationApprovals were obtained from the Alaska Area and University of Pittsburgh Institutional Review Boards and Alaska Native Tribal Health Consortium and Southcentral Foundation research review bodies. A data safety monitoring board, material transfer agreements and weekly study team meetings provide regular oversight throughout the study. Study findings will first be shared with AN tribal leaders, health administrators, providers and community members. Peer-reviewed journal articles and conference presentations will be forthcoming once approved by tribal review bodies.Trial registration numberNCT03028831.