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Background: Advance care planning empowers people by allowing them some control over certain healthcare decisions in the event they are unable. Yet, advance care planning rates in the American Indian and Alaska Native populations are low. Thus, we culturally tailored the Make Your Wishes About You (MY WAY), an intervention to improve advance care planning access and completion for American Indian peoples., Methods: In partnership with an American Indian Tribe, the project took a community-based participatory orientation and relied on a Community Advisory Board and a Professional Advisory Board. The culturally tailoring was a 15-step process. These steps allowed us to ensure that the tailoring reflects community-specific norms and preferences, greater reliance on visual images and local idioms of expression, more appropriate attention to family roles, and inclusion of spiritual elements., Results: A four-phase cultural tailoring framework emerged with each phase centering around listening, learning, and analyzing with tailoring occurring between each phase. A culturally tailored MY WAY was created, which was delivered in a manner that reflected Tribal citizenss' preferences. Materials included Tribal language, local idioms of expression, attention to family roles, and appropriate inclusion of spiritual elements. The materials were rated high on a content validity index by the advisory board members., Conclusion: There is a growing interest in tailoring existing evidence-based programs with relatively little in the literature offering guidance. By sharing our efforts and experiences in culturally tailoring an advance care planning program for an American Indian Tribe, we hope that it will serve useful for future efforts in ensuring that evidence-based programming reaches those in greatest need. While this project was rooted in the core Indigenous values of community, ceremony or spirituality, language, and place it also lends itself to broader translation across different populations.

As we age, the ability to move is foundational to health. Life space is one measure of a person's ability to move and engage in activity beyond the home. A separate but related concept is activity space, a measurement of a person's spatial behaviors and visited locations that include social networks, neighborhoods, and institutions. In this article, we integrate the literature on life space and activity space, discussing how physical function is not only determined by individual capabilities, but also by the surrounding social and environmental factors, which may limit their agency. We show how structural racism contributes to inequities within this paradigm linking related concepts of movement, agency, belonging, and timing. We also explore implications for research and theory for mobility, social connection, and activity., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Gerontological Society of America.)

Importance: Adolescent suicide in the US is a major public health problem, yet temporal trends in suicide methods by demographics are understudied., Objective: To examine national trends in suicide mortality by method (firearm, poisoning, hanging and asphyxiation, and all other means) from 1999 to 2020 by demographic characteristics., Design, Setting, and Participants: This serial cross-sectional study used national death certificate data of adolescent (aged 10-19 years) suicide decedents compiled by the National Center for Health Statistics from January 1, 1999, to December 31, 2020. Data analysis was performed from April 1, 2023, to July 9, 2023., Exposures: Age, sex, and race and ethnicity., Main Outcomes and Measures: Trends in age-standardized mortality rates and average annual percent change (AAPC) in rates were estimated by age, sex, and race and ethnicity for each suicide method., Results: This study assessed data from 47 217 adolescent suicide decedents. From 1999 to 2020, suicide by firearm (AAPC, 1.0; 95% CI, 0.1-1.9), poisoning (AAPC, 2.7; 95% CI, 1.0-4.4), hanging and asphyxiation (AAPC, 2.4; 95% CI, 0.2-4.6), and other means (AAPC, 2.9; 95% CI, 1.2-4.6) increased. Rapidly increasing rates were observed among female adolescents for poisoning (AAPC, 4.5; 95% CI, 2.3-6.7) and hanging and asphyxiation (AAPC, 5.9; 95% CI, 5.0-6.8) suicides. From 2007 to 2020, firearm suicides sharply increased among female (annual percent change [APC], 7.8; 95% CI, 6.0-9.5) and male (APC, 5.3; 95% CI, 4.3-6.3) adolescents. Firearm suicide rates increased among Black adolescents from 2012 to 2020 (APC, 14.5; 95% CI, 9.7-19.5), Asian and Pacific Islander adolescents from 2008 to 2020 (APC, 12.0; 95% CI, 9.7-14.5), American Indian and Alaska Native adolescents from 2014 to 2020 (APC, 10.6; 95% CI, 2.6-19.3), and Hispanic or Latino adolescents from 2011 to 2020 (APC, 10.2; 95% CI, 6.3-13.8). During the study period, Black adolescents had the highest average increase in hanging and asphyxiation suicides (AAPC, 4.2; 95% CI, 3.2-5.2). From 2011 to 2020, poisoning suicide deaths increased (APC, 12.6; 95% CI, 8.5-16.7) among female adolescents., Conclusions and Relevance: Suicide rates increased across all methods from 1999 to 2020. Differences were noted by sex, age, and race and ethnicity. Increasing suicide rates among racial and ethnic minoritized youth are especially concerning, and effective prevention strategies are urgently needed.

Navigating health care and insurance systems presents significant challenges for American Indian (AI) Elders. Access to culturally congruent assistance with decision-making, scheduling, transportation, and communication can bridge the gap between AI Elders and health systems. This study uses qualitative interviews with professionals providing navigation services to American Indian Elders in a Southwestern state to understand the skills, experiences, and challenges involved in delivering this support. We conducted semi-structured interviews with 16 professionals providing navigation support to AI Elders between November 2018 and August 2020 and used a constant comparative approach to identify themes. Participants' descriptions of their work centered on the themes of (1) respect for Elders; (2) wide-ranging responsibilities; (3) acting as a trusted communicator; (4) developing trust; and (5) challenges to providing navigation support for AI Elders. Efforts to achieve health equity for AI Elders must include supporting individuals such as these within communities and advocating for a just health care system for American Indian people.

Background: American Indian and Alaska Native peoples experience poor end-of-life care, including more hospitalizations and lower use of hospice and do-not-resuscitate orders. Although advance care planning (ACP) can improve end-of-life care, ACP rates are disproportionately low in American Indians and Alaska Natives., Objective: We culturally tailored and delivered an existing evidence-based ACP program for an American Indian tribal community. Here, we present the protocol for assessing the intervention's feasibility and efficacy., Methods: We measured feasibility via participant recruitment, participants' evaluation (acceptability, appropriateness, comprehension, and satisfaction), and intervention fidelity. Recruitment was measured with participant screening, eligibility, enrollment, and retention. Participant's evaluation of the intervention was measured with surveys. Fidelity was measured with direct observation and the Make Your Wishes About You (MY WAY) Fidelity Checklist Tool. To assess the intervention's efficacy, we used a quasi-experimental waitlist control design with 2 cohorts who were surveyed each on three separate occasions. The intervention's efficacy was assessed by the following: ACP barriers and facilitators as well as ACP self-efficacy, readiness, and completion., Results: A total of 166 participants were screened for eligibility; 11 were deemed ineligible, and 155 participants were enrolled in the study. Of those enrolled, 113 completed the intervention and will be included in subsequent analyses. We finalized data collection in January 2023, and analyses are underway. Study enrollment was successful, and we expect that participants will report high levels of acceptability, appropriateness, comprehension, and satisfaction with the intervention. We expect that the intervention was implemented with fidelity and will demonstrate decreases in ACP barriers and increases in ACP facilitators, self-efficacy, readiness, and completion., Conclusions: Enrolling over twice as many participants as we had hoped suggests that members of this tribal community are willing to engage in end-of-life ACP. We were able to implement a waitlist study design to show that a culturally tailored ACP program for a tribal community is feasible., Trial Registration: ClinicalTrials.gov NCT05304117; https://clinicaltrials.gov/study/NCT05304117., International Registered Report Identifier (irrid): DERR1-10.2196/50654., (©Elizabeth Anderson, R Turner Goins, Emily A Haozous, April Schweinhart. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 29.12.2023.)

Importance: Although deaths due to external causes are a leading cause of mortality in the US, trends over time by intent and demographic characteristics remain poorly understood., Objective: To examine national trends in mortality rates due to external causes from 1999 to 2020 by intent (homicide, suicide, unintentional, and undetermined) and demographic characteristics. External causes were defined as poisonings (eg, drug overdose), firearms, and all other injuries, including motor vehicle injuries and falls. Given the repercussions of the COVID-19 pandemic, US death rates for 2019 and 2020 were also compared., Design, Setting, and Participants: Serial cross-sectional study using national death certificate data obtained from the National Center for Health Statistics and including all external causes of 3 813 894 deaths among individuals aged 20 years or older from January 1, 1999, to December 31, 2020. Data analysis was conducted from January 20, 2022, to February 5, 2023., Exposures: Age, sex, and race and ethnicity., Main Outcomes and Measures: Trends in age-standardized mortality rates and average annual percentage change (AAPC) in rates calculated by intent (suicide, homicide, unintentional, and undetermined), age, sex, and race and ethnicity for each external cause., Results: Between 1999 and 2020, there were 3 813 894 deaths due to external causes in the US. From 1999 to 2020, poisoning death rates increased annually (AAPC, 7.0%; 95% CI, 5.4%-8.7%). From 2014 to 2020, poisoning death rates increased the most among men (APC, 10.8%; 95% CI, 7.7%-14.0%). During the study period, poisoning death rates increased in all the racial and ethnic groups examined; the most rapid increase was among American Indian and Alaska Native individuals (AAPC, 9.2%; 95% CI, 7.4%-10.9%). During the study period, death rates for unintentional poisoning had the most rapid rate of increase (AAPC, 8.1%; 95% CI, 7.4%-8.9%). From 1999 to 2020, firearm death rates increased (AAPC, 1.1%; 95% CI, 0.7%-1.5%). From 2013 to 2020, firearm mortality increased by an average of 4.7% annually (95% CI, 2.9%-6.5%) among individuals aged 20 to 39 years. From 2014 to 2020, mortality from firearm homicides increased by an average of 6.9% annually (95% CI, 3.5%-10.4%). From 2019 to 2020, mortality rates from external causes accelerated further, largely from increases in unintentional poisoning, and homicide due to firearms and all other injuries., Conclusions and Relevance: Results of this cross-sectional study suggest that from 1999 to 2020, death rates due to poisonings, firearms, and all other injuries increased substantially in the US. The rapid increase in deaths due to unintentional poisonings and firearm homicides is a national emergency that requires urgent public health interventions at the local and national levels.

Background: Starting in 2018, national death certificates included a new racial classification system that accounts for multiple-race decedents and separates Native Hawaiian and Pacific Islander (NHPI) individuals from Asian individuals. We estimated cancer death rates across updated racial and ethnic categories, sex, and age., Methods: Age-standardized US cancer mortality rates and rate ratios from 2018 to 2020 among individuals aged 20 years and older were estimated with national death certificate data by race and ethnicity, sex, age, and cancer site., Results: In 2018, there were approximately 597 000 cancer deaths, 598 000 in 2019, and 601 000 in 2020. Among men, cancer death rates were highest in Black men (298.2 per 100 000; n = 105 632), followed by White (250.8; n = 736 319), American Indian/Alaska Native (AI/AN; 249.2; n = 3376), NHPI (205.6; n = 1080), Latino (177.2; n = 66 167), and Asian (147.9; n = 26 591) men. Among women, Black women had the highest cancer death rates (206.5 per 100 000; n = 104 437), followed by NHPI (192.1; n = 1141), AI/AN (189.9; n = 3239), White (183.0; n = 646 865), Latina (128.4; n = 61 579), and Asian (111.4; n = 26 396) women. The highest death rates by age group occurred among NHPI individuals aged 20-49 years and Black individuals aged 50-69 and 70 years and older. Asian individuals had the lowest cancer death rates across age groups. Compared with Asian individuals, total cancer death rates were 39% higher in NHPI men and 73% higher in NHPI women., Conclusions: There were striking racial and ethnic disparities in cancer death rates during 2018-2020. Separating NHPI and Asian individuals revealed large differences in cancer mortality between 2 groups that were previously combined in vital statistics data., (© The Author(s) 2023. Published by Oxford University Press.)

Context: American Indian elders have a lower life expectancy than other aging populations in the United States because of inequities in health and in access to health care. To reduce such disparities, the 2010 Affordable Care Act included provisions to increase insurance enrollment among American Indians. Although the Indian Health Service remains underfunded, increases in insured rates have had significant impacts among American Indians and their health care providers., Methods: From June 2016 to March 2017, we conducted qualitative interviews with 96 American Indian elders (age 55+) and 47 professionals (including health care providers, outreach workers, public-sector administrators, and tribal leaders) in two southwestern states. Interviews focused on elders' experiences with health care and health insurance. We analyzed transcripts iteratively using open and focused coding techniques., Findings: Although tribal health programs have benefitted from insurance payments, the complexities of selecting, qualifying for, and maintaining health insurance are often profoundly alienating and destabilizing for American Indian elders and communities., Conclusions: Findings underscore the inadequacy of health-system reforms based on the expansion of private and individual insurance plans in ameliorating health disparities among American Indian elders. Policy makers must not neglect their responsibility to directly fund health care for American Indians., (Copyright © 2022 by Duke University Press.)

Having a regular relationship with a healthcare provider contributes to better health outcomes and greater satisfaction with care for older adults. Although members of federally recognized American Indian tribes have a legal right to healthcare, American Indian Elders experience inequities in healthcare access that may compromise their ability to establish a relationship with a healthcare provider. This multi-year, community-driven, mixed-method study examines the potential causes and consequences of not having a personal healthcare provider among American Indian Elders. Quantitative surveys and qualitative interviews were conducted with 96 American Indian Elders (age 55 and over) in two states in the Southwestern United States. Quantitative and qualitative data were analyzed separately and then triangulated to identify convergences and divergences in data. Findings confirmed that having a consistent healthcare provider correlated significantly with self-rated measures of health, confidence in getting needed care, access to overall healthcare, and satisfaction with care. Lack of a regular healthcare provider was related to interconnected experiences of self-reliance, bureaucratic and contextual barriers to care, and sentiments of fear and mistrust based in previous interactions with medical care. Increasing health equity for American Indian Elders will thus require tailored outreach and system change efforts to increase continuity of care and provider longevity within health systems and build Elders' trust and confidence in healthcare providers., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Jaramillo, Sommerfeld, Haozous, Brunner and Willging.)

American Indian (AI) Elders are the heart of the community. Existing research explores links between specific health behaviors and social determinants of health, but there is little theory explaining patient behaviors in the context of the Indian Health Service (IHS) system of care. We drew from a multiyear mixed-methods participatory study of Elder healthcare experiences to identify the systemic, interpersonal, and historic factors in the IHS that impact their health-seeking behaviors. We conducted an interpretive grounded theory analysis guided by Indigenous methodologies to analyze interviews with 96 AI Elders from two Southwestern states. Our resulting theory, Getting to Know , explains how Elders knew, owned, accessed, and were denied information and resources in their efforts to receive care. Findings highlight how Elders' health-seeking behaviors reflect longstanding inequities, the many ways Elder knowledge was incongruent with Western knowledge embedded in the IHS system, and how this conflict contributed to Elder discomfort in clinical settings. Future work will test the applicability of Getting to Know in other AI communities and design culturally safe care to meet Elder needs. By applying an Indigenous-centered analysis to the voices of Elders, we identified key influences on health outcomes not previously observed in the literature. By illuminating these influences, we show how culturally safe care can be better formulated to meet the needs of Elders, ultimately improving health for AI communities.

Background: Although racial/ethnic disparities in U.S. COVID-19 death rates are striking, focusing on COVID-19 deaths alone may underestimate the true effect of the pandemic on disparities. Excess death estimates capture deaths both directly and indirectly caused by COVID-19., Objective: To estimate U.S. excess deaths by racial/ethnic group., Design: Surveillance study., Setting: United States., Participants: All decedents., Measurements: Excess deaths and excess deaths per 100 000 persons from March to December 2020 were estimated by race/ethnicity, sex, age group, and cause of death, using provisional death certificate data from the Centers for Disease Control and Prevention (CDC) and U.S. Census Bureau population estimates., Results: An estimated 2.88 million deaths occurred between March and December 2020. Compared with the number of expected deaths based on 2019 data, 477 200 excess deaths occurred during this period, with 74% attributed to COVID-19. Age-standardized excess deaths per 100 000 persons among Black, American Indian/Alaska Native (AI/AN), and Latino males and females were more than double those in White and Asian males and females. Non-COVID-19 excess deaths also disproportionately affected Black, AI/AN, and Latino persons. Compared with White males and females, non-COVID-19 excess deaths per 100 000 persons were 2 to 4 times higher in Black, AI/AN, and Latino males and females, including deaths due to diabetes, heart disease, cerebrovascular disease, and Alzheimer disease. Excess deaths in 2020 resulted in substantial widening of racial/ethnic disparities in all-cause mortality from 2019 to 2020., Limitations: Completeness and availability of provisional CDC data; no estimates of precision around results., Conclusion: There were profound racial/ethnic disparities in excess deaths in the United States in 2020 during the COVID-19 pandemic, resulting in rapid increases in racial/ethnic disparities in all-cause mortality between 2019 and 2020., Primary Funding Source: National Institutes of Health Intramural Research Program.

The COVID-19 pandemic has inequitably impacted Indigenous communities in the United States. In this emergency state that highlighted existing inadequacies in US government and tribal public health infrastructures, many tribal nations contracted with commercial entities and other organization types to conduct rapid diagnostic and antibody testing, often based on proprietary technologies specific to the novel pathogen. They also partnered with public-private enterprises on clinical trials to further the development of vaccines. Indigenous people contributed biological samples for assessment and, in many cases, broadly consented for indefinite use for future genomics research. A concern is that the need for crisis aid may have placed Indigenous communities in a position to forego critical review of data use agreements by tribal research governances. In effect, tribal nations were placed in the unenviable position of trading short-term public health assistance for long-term, unrestricted access to Indigenous genomes that may disempower future tribal sovereignties over community members' data. Diagnostic testing, specimen collection, and vaccine research is ongoing; thus, our aim is to outline pathways to trust that center current and future equitable relationship-building between tribal entities and public-private interests. These pathways can be utilized to increase Indigenous communities' trust of external partners and share understanding of expectations for and execution of data protections. We discuss how to navigate genomic-based data use agreements in the context of pathogen genomics. While we focus on US tribal nations, Indigenous genomic data sovereignties relate to global Indigenous nations regardless of colonial government recognition., Competing Interests: KT serves as a non-compensated board member of a non-profit 501(c)3 Indigenous biobank initiative, the Native BioData Consortium, in the United States. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Haring, Blanchard, Korchmaros, Lund, Haozous, Raphaelito, Hudson and Tsosie.)

Background: The US remains in the midst of an opioid overdose epidemic. Given that rural populations have higher rates of opioid-related morbidity and mortality, it is important to understand the factors that perpetuate opioid use and facilitate recovery in rural communities. Purpose : To explore experiences of individuals living with opioid use disorder (OUD) and to analyze these experiences within a broader sociocultural context. Methods : Using a descriptive, qualitative design, we interviewed twenty purposefully sampled participants. We used thematic content analysis to identify themes and patterns. Results : As participants became dependent, the chase for opioids was to avoid the pain of withdrawal. Waking up sick became an everyday experience, leading to a lifestyle of hustling. The pursuit of opioids resulted in physical, social, emotional, and legal consequences that fed a cycle of stigmatization. In recovery, participants learned to embrace a new way of thinking, allowing them to make new choices. The strong influence of family and community in their lives was a key factor in their resiliency and opioid use experiences. Conclusions : Individuals with OUD are impacted by intersecting social, physical, economic and policy factors that reinforce the expansion of the opioid epidemic rurally. This study provided a voice to rural individuals with opioid use disorder, a group often underrepresented in the literature, providing an understanding of their struggles and the unique sociocultural dynamics that exist in rural northern New Mexico. The complex sociocultural relationships to family and community represent important adaptive factors that could support individual healing and community transformation.

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

Medication-assisted treatment (MAT) for opioid use disorder (OUD) is accessed half as often in rural versus urban areas in the United States. To better understand this disparity, we used a qualitative descriptive approach to explore the experiences of individuals with OUD seeking MAT in rural New Mexico. Guided interviews were conducted with 20 participants. The frameworks of critical social theory, intersectionality theory, and the brain opioid theory of social attachment were used to guide data analysis and interpretation. Thematic content analysis derived five major themes which identified novel barriers and facilitators to MAT success, including a perceived gender disparity in obtaining MAT, challenges in building a recovery-oriented support system, and the importance of navigating a new normal social identity. This deeper knowledge of the experiences and perspectives of rural individuals with OUD could serve to address the rural-urban MAT disparity, leading to enhanced recovery capacity and transformative policies.

Importance: Life expectancy has decreased in the US, driven largely by increases in drug poisoning, suicide, and alcohol-induced deaths. Assessing whether patterns of these causes differ is required to inform public health interventions., Objective: To compare patterns and trends in drug poisoning, suicide, and alcohol-induced death rates by geography and demographic characteristics., Design, Setting, and Participants: This serial cross-sectional study used national vital statistics data from the entire US population from January 1, 2000, to December 31, 2017, among US residents aged 20 to 64 years. Data were analyzed from January through August 2019., Exposures: Age, sex, race/ethnicity, county-level percentage of unemployment, rurality, and geography., Main Outcomes and Measures: Deaths were categorized as due to drug poisoning, suicide, or alcohol-induced causes based on underlying cause of death. Age-standardized incidence rates and annual percentage changes (APCs) in rates were estimated. Clusters of high-rate counties were identified with hot spot analysis. Excess deaths during 2001 to 2017 were estimated for each cause as the difference between the number of deaths observed and expected if rates had remained stable starting in 2000., Results: During 2000 to 2017, 1 446 177 drug poisoning, suicide, and alcohol-induced premature deaths occurred in the US, including 563 765 drug poisoning deaths (age-standardized rate: 17.6 per 100 000 person-years [PYs]), 517 679 suicides (age-standardized rate: 15.8 per 100 000 PYs), and 364 733 alcohol-induced deaths (age-standardized rate: 10.5 per 100 000 PYs), totaling 451 596 more deaths than expected based on 2000 rates. High drug poisoning death rates were clustered in the Northeast through Appalachia, yet rates of suicide and alcohol-induced deaths were highest in the West. Only suicide death rates were highest in rural areas. Drug poisoning death rates were highest among people aged 35 to 49 years (age-standardized rate: 23.7 per 100 000 PYs), whereas suicide and alcohol-induced death rates peaked among people aged 50 to 64 years (suicide age-standardized rate: 19.6 per 100 000 PYs; alcohol-induced age-standardized death rate: 26.8 per 100 000 PYs). Increases occurred over time across racial/ethnic groups, although trajectories and inflection years varied. Drug poisoning (2013-2017 APC, 15.0% [95% CI, 11-8%-18.3%] per year) and alcohol-induced death rates (2012-2017 APC, 4.1% [95% CI, 3.3%-4.9%] per year) have accelerated recently, while increases in suicide death rates have largely increased at a constant trajectory (2000-2017 APC, 1.8% [95% CI, 1.7%-1.9%] per year)., Conclusions and Relevance: This cross-sectional study found that demographic characteristics and geographic patterns varied by cause of death, suggesting that increasing death rates from these causes were not concentrated in 1 group or region. Specialized interventions tailored for the underlying drivers of each cause of death are urgently needed.

Importance: Notable increases in mortality from alcohol-induced causes over the past 2 decades in the United States have been reported. However, comprehensive assessments of trends in alcohol-induced mortality by sex, age, race/ethnicity, and social and geographic factors are lacking., Objective: To examine trends in alcohol-induced mortality rates from 2000 to 2016, comparing results by demographic characteristics including sex, race/ethnicity, age, county-level socioeconomic status, and geographic location., Design, Setting, and Participants: This serial cross-sectional study used US national vital statistics data for years 2000 to 2016 for all US residents older than 15 years. Data analysis was conducted from January to September 2019., Exposures: Trends in alcohol-induced mortality by sex, race/ethnicity, age, county-level socioeconomic status (ie, median income, percentage of unemployed residents, percentage of residents with a bachelor's degree), rurality level, and US state., Main Outcomes and Measures: Alcohol-induced mortality, ie, deaths for which alcohol holds a population-attributable fraction of 1. Deaths were expressed per 100 000 residents as absolute and age-standardized rates. Mortality trends were measured as average annual percentage changes (AAPCs) for the entire period (ie, 2000-2016) and annual percentage changes (APCs) for individual periods of change within the study period., Results: A total of 425 045 alcohol-induced deaths were identified from 2000 to 2016 (2000: 19 627 deaths; 14 979 [76.3%] men; 2016: 34 857 deaths; 25 213 [73.3%] men). The rate of alcohol-induced deaths increased substantially among men (AAPC, 1.4%; 95% CI, 1.0% to 1.8%) and women (AAPC, 3.1%; 95% CI, 2.6% to 3.6%) and accelerated recently (men, 2012-2016: APC, 4.2%; 95% CI, 3.1% to 5.3%; women, 2013-2016: APC, 7.1%; 95% CI, 5.1% to 9.1%). The largest increases by race/ethnicity were observed among American Indian and Alaska Native men (AAPC, 3.3%; 95% CI, 2.6% to 4.0%), American Indian and Alaska Native women (AAPC, 4.2%; 95% CI, 3.8% to 4.6%), and white women (AAPC, 4.1%; 95% CI, 3.6% to 4.7%). Despite initial declines among black women, black men, and Latino men (eg, Latino men, 2000-2003: APC, -5.1%; 95% CI, -9.8% to -0.1%; 2003-2013: APC, -0.6%; 95% CI, -1.4% to 0.2%), increases occurred later in the study period (eg, Latino men, 2013-2016: APC, 4.1%; 95% CI, 0.3% to 8.1%). The rates of increase varied by age group and in turn by racial/ethnic group. Among white individuals, large absolute increases occurred in midlife (eg, men aged 55-59 years, 2000-2003: 25.5 deaths per 100 000 residents; 2013-2016: 43.3 deaths per 100 000 residents; women aged 50-54 years, 2000-2003: 7.4 deaths per 100 000 residents; 2013-2016: 16.5 deaths per 100 000 residents), although APCs were also large for ages 25 to 34 years, ranging from 4.6% to 6.9% per year among men and from 7.3% to 12.0% among women. Among American Indian and Alaska Native individuals, increases throughout the age range were observed, with the largest absolute increase occurring for ages 45 to 49 years among men (2000-2013: 113.6 deaths per 100 000 residents; 2013-2016: 193.1 deaths per 100 000 residents) and for ages 50 to 54 among women (2000-2013: from 56.1 deaths per 100 000 residents; 2013-2016: 105.1 deaths per 100 000 residents)., Conclusions and Relevance: This study found large increases in alcohol-induced death rates across age and racial/ethnic subgroups of the US population, which have accelerated over recent years. Large increases in alcohol-induced deaths among younger age groups may be associated with future increases in alcohol-related disease.

American Indians and Alaska Natives (AIANs) have been documented as a population with high rates of cancer mortality in comparison to other racial and ethnic groups in the United States. During a time when other populations in the United States are experiencing improvements in cancer outcomes, cancer disparities in AIANs persist. The disparities in cancer outcomes in this diverse population can be attributed to a complex constellation of factors, which include access-to-care, economic, medical, and individual barriers, and mistrust and disenfranchisement.

With mounting pressure to move toward precision health care and implementation science, nurse researchers are faced with the challenge of producing evidence that their interventions are applicable in real-world clinical settings. Pragmatic clinical trials are critically important to generate evidence that is relevant to clinical practice. Pragmatic designs closely replicate true-to-life settings thereby expediting research translation and improving health outcomes. The Sequential Multiple Assignment Randomized Trial (SMART) is a valuable a pragmatic trial design that is receiving greater attention in nursing. SMART designs can be used to provide relevant clinical evidence by comparative evaluation of two or more alternative interventions. The objectives of this article are to provide: (a) A description of the main considerations and key components of SMART designs, and (b) a summary of three different nursing studies using SMART designs. Information provided by pragmatic nursing trials using SMART designs, which more closely mirror clinical practice, will facilitate evidence-based clinical practice., (© 2019 Wiley Periodicals, Inc.)

Importance: The United States has higher infant and youth mortality rates than other high-income countries, with striking disparities by racial/ethnic group. Understanding changing trends by age and race/ethnicity for leading causes of death is imperative for focused intervention., Objective: To estimate trends in US infant and youth mortality rates from 1999 to 2015 by age group and race/ethnicity, identify leading causes of death, and compare mortality rates with Canada and England/Wales., Design, Setting, and Participants: This descriptive study analyzed death certificate data from the US National Center for Health Statistics, Statistics Canada, and the UK Office of National Statistics for all deaths among individuals younger than 25 years. The study took place from January 1, 1999, to December 31, 2015, and analyses started in September 2017., Exposures: Race/ethnicity., Main Outcomes and Measures: Average annual percent changes in mortality rates from 1999 to 2015 and absolute rate change between 1999 to 2002 and 2012 to 2015 for each age group, race/ethnicity, and cause of death., Results: Among individuals from birth to age 24 years, 1 169 537 deaths occurred in the United States, 80 540 in Canada, and 121 183 in England/Wales from 1999 to 2015. In the United States, 64% of deaths occurred in male individuals and 52.6% occurred in white individuals (25.1% deaths occurred in black individuals and 17.9% in Latino individuals). All-cause mortality declined for all age groups (infants younger than 1 year [38.5% of deaths], children aged 1-9 years [10.6%], early adolescents aged 10-14 years [5%], late adolescents aged 15-19 years [17.7%], and young adults aged 20-24 years [28.1%]) in the United States, Canada, and England/Wales from 1999 to 2015. However, rates were highest in the United States. Within the United States, annual declines in all-cause mortality rates occurred among all age groups of black, Latino, and white individuals, except for white individuals aged 20 to 24 years, whose rates remained stable. Mortality rates declined across most major causes of death from 1999 to 2002 and 2012 to 2015, with notable declines observed for sudden infant death syndrome, unintentional injury death, and homicides. Among infants, unintentional suffocation and strangulation in bed increased (difference between 2012-2015 and 1999-2002 range, 6.11-29.03 per 100 000). Further, suicide rates among Latino and white individuals aged 10 to 24 years (range, 0.21-2.63 per 100 000) and black individuals aged 10 to 19 years (range, 0.10-0.45 per 100 000) increased, as did unintentional injury deaths in white young adults (0.79 per 100 000). The rise in unintentional injury deaths is attributed to increases in drug poisonings and was also observed in black and Latino young adults., Conclusions and Relevance: Mortality rates in the United States have generally declined for infants and youths from 1999 to 2015 owing to reductions in sudden infant death syndrome, unintentional injury death, and homicides. However, US mortality rates remain higher than Canada and England/Wales, with particularly elevated rates among black and American Indian/Alaskan Native youth. Further, there is a concerning increase in suicide and drug poisoning death rates among US adolescents and young adults.

Background: Although life expectancy has been projected to increase across high-income countries, gains for the USA are anticipated to be among the smallest, and overall US death rates actually increased from 2014 to 2015, with divergence for specific US populations. Therefore, projecting future premature mortality is essential for clinical and public health service planning, curbing rapidly increasing causes of death, and sustaining progress in declining causes of death. We aimed to project premature mortality (here defined as deaths of individuals aged 25-64 years) trends through 2030, and to estimate the total number of projected deaths, the projected number of potential years of life lost due to premature mortality, and the effect of reducing projected accidental death rates by 2% per year., Methods: We obtained death certificate data for the US population aged 25-64 years for 1990-2015 from the US Centers for Disease Control and Prevention (CDC) National Center for Health Statistics. We obtained US mortality data for 2016 for non-American Indian or Alaska native groups from CDC WONDER; data for 2016 were not available for American Indians or Alaska natives. Our analysis focused on all-cause premature mortality and the commonest causes of premature death (cancer, heart disease, accidents, suicide, and chronic liver disease or cirrhosis) among white, black, Hispanic, Asian or Pacific islanders, and American Indian or Alaska native men and women. We estimated age-standardised premature mortality and corresponding annual percentage changes for 2017-30 by sex and race or ethnic origin by use of age-period-cohort forecasting models. We also did a sensitivity analysis projecting future mortality from cross-sectional mortality and a JoinPoint of the (log) period rate ratio curve. We calculated absolute death counts by use of corresponding age-specific and year-specific US census population projections, and estimated years of potential life lost., Findings: During 2017-30, all-cause deaths are projected to increase among white women and American Indians or Alaska natives, resulting in 239 700 excess premature deaths relative to 2017 rates (a 10% increase). Mortality declines in white men and black, Hispanic, and Asian or Pacific islander men and women will result in 945 900 fewer deaths (a 14% reduction). Cancer mortality rates are projected to decline among white, black, Hispanic, and Asian or Pacific islander women and men, with the largest declines among black women (age-standardised premature mortality rate 2016: 104·5 deaths per 100 000 woman-years; 2030: 77·1 per 100 000 woman-years) and men (2016: 116·8 per 100 000 man-years; 2030: 81·6 per 100 000 man-years). Heart disease death rates are projected to increase in American Indian or Alaska native men (2015: 150·9 per 100 000 man-years; 2030: 175·9 per 100 000 man-years) and decline in other groups, albeit only slightly in white (2016: 35·6 per 100 000 woman-years; 2030: 31·1 per 100 000 woman-years) and American Indian or Alaska native women (2015: 64·4 per 100 000 woman-years; 2030: 62·8 per 100 000 woman-years). Accidental death rates are projected to increase in all US populations except Asian or Pacific islander women, and will increase most rapidly among white women (2030: 60·5 per 100 000 woman-years) and men (2030: 101·9 per 100 000 man-years) and American Indian or Alaska native women (2030: 97·5 per 100 000 woman-years) and men (2030: 298·7 per 100 000 man-years). Suicide rates are projected to increase for all groups, and chronic liver disease and cirrhosis deaths are projected to increase for all groups except black men. A 2% per year reduction in projected accidental deaths would eliminate an estimated 178 700 deaths during 2017-30., Interpretation: To reduce future premature mortality, effective interventions are needed to address rapidly rising mortality rates due to accidents, suicides, and chronic liver disease and cirrhosis., Funding: National Cancer Institute Intramural Research Program., (Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

In 1886, the U.S. government took the last of the free Chiricahua Apaches captive, closing the chapter on the Indian Wars in the United States. Emily Haozous, a descendent of those original captives, describes her circuitous path back to New Mexico as part of her own journey through academic nursing 110 year later.

Background: Reduction of premature mortality is a UN Sustainable Development Goal. Unlike other high-income countries, age-adjusted mortality in the USA plateaued in 2010 and increased slightly in 2015, possibly because of rising premature mortality. We aimed to analyse trends in mortality in the USA between 1999 and 2014 in people aged 25-64 years by age group, sex, and race and ethnicity, and to identify specific causes of death underlying the temporal trends., Methods: For this analysis, we used cause-of-death and demographic data from death certificates from the US National Center for Health Statistics, and population estimates from the US Census Bureau. We estimated annual percentage changes in mortality using age-period-cohort models. Age-standardised excess deaths were estimated for 2000 to 2014 as observed deaths minus expected deaths (estimated from 1999 mortality rates)., Findings: Between 1999 and 2014, premature mortality increased in white individuals and in American Indians and Alaska Natives. Increases were highest in women and those aged 25-30 years. Among 30-year-olds, annual mortality increases were 2·3% (95% CI 2·1-2·4) for white women, 0·6% (0·5-0·7) for white men, and 4·3% (3·5-5·0) and 1·9% (1·3-2·5), respectively, for American Indian and Alaska Native women and men. These increases were mainly attributable to accidental deaths (primarily drug poisonings), chronic liver disease and cirrhosis, and suicide. Among individuals aged 25-49 years, an estimated 111 000 excess premature deaths occurred in white individuals and 6600 in American Indians and Alaska Natives during 2000-14. By contrast, premature mortality decreased substantially across all age groups in Hispanic individuals (up to 3·2% per year), black individuals (up to 3·9% per year), and Asians and Pacific Islanders (up to 2·6% per year), mainly because of declines in HIV, cancer, and heart disease deaths, resulting in an estimated 112 000 fewer deaths in Hispanic individuals, 311 000 fewer deaths in black individuals, and 34 000 fewer deaths in Asians and Pacific Islanders aged 25-64 years. During 2011-14, American Indians and Alaska Natives had the highest premature mortality, followed by black individuals., Interpretation: Important public health successes, including HIV treatment and smoking cessation, have contributed to declining premature mortality in Hispanic individuals, black individuals, and Asians and Pacific Islanders. However, this progress has largely been negated in young and middle-aged (25-49 years) white individuals, and American Indians and Alaska Natives, primarily because of potentially avoidable causes such as drug poisonings, suicide, and chronic liver disease and cirrhosis. The magnitude of annual mortality increases in the USA is extremely unusual in high-income countries, and a rapid public health response is needed to avert further premature deaths., Funding: US National Cancer Institute Intramural Research Program., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Racial and ethnic diversity among nursing faculty is low, preventing schools of nursing (SON) from reflecting the populations that they serve academically and clinically. Few studies address the experience and success of faculty of color (FOC) in nursing., Purpose: The purpose of this article is to summarize the current literature related to FOC retention and promotion., Methods: We reviewed 25 articles from the nursing literature following PRISMA guidelines, using a critical race theory framework., Discussion: We describe barriers and promoters to retention, benefits of retaining FOC, and proposed solutions to FOC attrition. We also highlight polices by several SON that netted increased retention and promotion of nursing FOC., Conclusion: FOC meet substantial challenges that influence their career pathway. SON can improve faculty retention through focused efforts on improving the institutional culture to promote an inclusive environment., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Little is known about optimal palliative and end-of-life care for American Indians and Alaska Natives (AIs/ANs)., Methods: We searched MEDLINE, the Cochrane library, EBSCOhost, (PsycINFO, CINAHL Complete), and the University of New Mexico (UNM) Health Sciences Library and Informatics Center Native Health Database for search terms related to palliative care and AIs/ANs as of December 1, 2015. We included English language, peer-reviewed articles describing palliative care projects, programs, or studies in AI/AN populations or communities. We excluded case series, opinion or reflection pieces, and dissertations and articles addressing Pacific Islanders., Results: Our search strategy yielded 294 references, of which we included 10 publications. Study methods and outcome measures were heterogeneous, and many studies were small and/or subject to multiple biases. Common themes included the importance of culturally appropriate communication, multiple barriers to treatment, and less frequent use of advance directives than other populations., Conclusions: Heterogeneity of study types, population, and small sample sizes makes it hard to draw broad conclusions regarding the best way to care for AIs/ANs. More studies are needed to assess this important topic.

Purpose/objectives: To describe the experiences of American Indian and Alaska Native cancer survivors to improve understanding of the trajectory of cancer treatment. 
., Research Approach: Qualitative focus group research.
., Setting: Rural and geographically isolated American Indian and Alaska Native communities in the Pacific Northwest.
., Participants: 30 American Indian and Alaska Native cancer survivors or caregivers. 
., Methodologic Approach: The authors analyzed data from two focus groups with cancer survivors by using thematic analysis informed by indigenous methodologies.
., Findings: Based on focus group findings, the authors developed a conceptual model of the cancer experience called Rough Waters. Participants described their cancer experience as a collective journey involving family and friends and requiring resources to offset challenges along the way. Dominant themes were delays, isolation, communication, money, advocacy, spirituality, and family involvement.
., Conclusions: American Indians and Alaska Natives in the Pacific Northwest have special cultural needs during cancer care. The current study provides examples that can guide patient-provider interactions.
., Interpretation: Using the metaphor of cancer as a journey, clinicians can begin a dialogue to identify what will impede or assist the cancer journey for their American Indian and Alaska Native patients.

Purpose: The purpose of this project was to explore the chronic pain experience and establish cultural appropriateness of cognitive behavioral pain management (CBPM) techniques in American Indians and Alaska Natives (AI/ANs)., Design: A semistructured interview guide was used with three focus groups of AI/AN patients in the U.S. Southwest and Pacific Northwest regions to explore pain and CBPM in AI/ANs., Findings: The participants provided rich qualitative data regarding chronic pain and willingness to use CBPM. Themes included empty promises and health care insufficiencies, individuality, pain management strategies, and suggestions for health care providers., Conclusion: Results suggest that there is room for improvement in chronic pain care among AI/ANs and that CBPM would likely be a viable and culturally appropriate approach for chronic pain management., Implications: This research provides evidence that CBPM is culturally acceptable and in alignment with existing traditional AI/AN strategies for coping and healing., (© The Author(s) 2014.)

Purpose: Racial and ethnic minority groups in the United States have the highest mortality rates for the most common cancers. Various factors, including a perceived lack of culturally congruent care and culturally competent providers, might lead minority patients to decline or delay care. As part of a large multimethod study to understand barriers to care among American Indian and Alaskan native patients with cancer, we examined surgical provider attributes associated with culturally congruent care., Patients and Methods: Surgical providers from six hospitals in the Puget Sound region of Washington State were invited to participate. Participants completed a 50-item survey that assessed demographic data and incorporated the Cultural Competence Assessment (CCA) and the Marlowe-Crowne Social Desirability Scale., Results: Survey response rate was 51.1% (N = 253). Participants reported treating diverse patient populations; 71% encountered patients from six or more racial and ethnic groups. More than one half of participants (58%) reported completing cultural diversity training, with employer-sponsored training being the most common type reported (48%; 71 of 147). CCA scores ranged from 5.99 to 13.75 of a possible 14 (mean, 10.3; standard deviation, ±1.3), and receipt of diversity training was associated with higher scores than nonreceipt of diversity training (10.56 v 9.82, respectively; P<.001). After controlling for Marlowe-Crowne Social Desirability Scale score and hospital system,participation in diversity training was the variable most significantly associated with CCA score (P<.001)., Conclusion: Culturally competent care is an essential but often overlooked component of high-quality health care. Future work should compare training offered by various hospital systems.

This article presents a review of the literature to identify best practices for clinical partnerships with indigenous populations of North America, specifically American Indian/Alaska Native, First Nations, Métis, and Inuit of Canada. The authors have identified best practices and lessons learned from collaborating with indigenous populations, presented in 2 categories: conceptual guidelines and health care delivery guidelines. Major themes include the importance of trust and communication, the delivery of culturally congruent health care, and the necessity of working in partnership with tribal entities for successful delivery of health care. Best practices in health care delivery with indigenous populations are presented., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Misclassification of race in medical and mortality records has long been documented as an issue in American Indian/Alaska Native data. Yet, little has been shared in a cohesive narrative which outlines why misclassification of American Indian/Alaska Native identity occurs. The purpose of this paper is to provide a summary of the current state of the science in racial misclassification among American Indians and Alaska Natives. We also provide a historical context on the importance of this problem and describe the ongoing political processes that both affect racial misclassification and contribute to the context of American Indian and Alaska Native identity.

To assess decision-making for cancer treatment among racial/ethnic minority patients, we systematically reviewed and synthesized evidence from studies of "shared decision-making," "cancer," and "minority groups," using PubMed, PsycInfo, CINAHL, and EMBASE. We identified significant themes that we compared across studies, refined, and organized into a conceptual model. Five major themes emerged: treatment decision-making, patient factors, family and important others, community, and provider factors. Thematic data overlapped categories, indicating that individuals' preferences for medical decision-making cannot be authentically examined outside the context of family and community. The shared decision-making model should be expanded beyond the traditional patient-physician dyad to include other important stakeholders in the cancer treatment decision process, such as family or community leaders.

Context: Although minority patients with cancer are more likely to be undermedicated for cancer pain than non-Hispanic whites, little is known about the experience of cancer pain in American Indians (AIs)., Objectives: To describe the experience of cancer and cancer pain in a sample of southwestern AIs., Methods: Ethnographic interviews were conducted with 13 patients and 11 health care providers, caregivers, and community members; two questionnaires were used to collect demographic and pain data., Results: Barriers to pain control among AIs included difficulties describing pain, a belief that cancer pain is inevitable and untreatable, and an aversion to taking opioid pain medication. Prescriber inexperience also was cited as a barrier to pain management. AIs described a strong desire to protect their privacy regarding their illness, and many felt that expressing pain was a sign of weakness. The inability to participate in spiritual and cultural activities caused AIs distress, and some discontinued treatment or missed chemotherapy appointments to engage in these activities., Conclusion: Results revealed new knowledge about the cancer pain experience in AIs. The observation of the close relationship between treatment compliance and the patient's ability to participate in ceremonial and spiritual activities provides new insight into the problem of incomplete cancer treatment in this population. The finding that AI patients have a multidimensional conceptualization of pain will assist clinicians with obtaining more detailed and informative pain assessments., (Copyright © 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Dissemination and implementation (D&I) research is a growing area of science focused on overcoming the science-practice gap by targeting the distribution of information and adoption of interventions to public health and clinical practice settings. This study examined D&I research projects funded under specific program announcements by the US National Institutes of Health (NIH) from 2005 to 2012. The authors described the projects' D&I strategies, funding by NIH Institute, focus, characteristics of the principal investigators (PIs) and their organizations, and other aspects of study design and setting. Results showed 46 R01s, 6 R03s, and 24 R21s funded totaling $79.2 million. The top funders were the National Cancer Institute and the National Institute of Mental Health, together providing 61% of funding. The majority of PIs were affiliated with Schools of Medicine or large, nonprofit research organizations and think tanks. Only 4% of projects were to PIs with appointments at Schools of Nursing, with 7% of the funding. The most commonly funded projects across all of the studies focused on cancer control and screening, substance abuse prevention and treatment, and mental health services. Typically implemented in community and organizational settings, D&I research provides an excellent opportunity for team science, including nurse scientists and interdisciplinary collaborators.

Healthcare providers serving rural populations face numerous barriers to accessing educational programming. Difficulties accessing continuing professional education contribute to the challenges of providing comprehensive health care in the rural setting. Telehealth can inform and educate rural providers about changes in medicine and evidence-based practices, both of which may help them provide quality care. The Native People for Cancer Control Telehealth Network used telehealth technology to deliver a cancer education series in 2008 and 2009 to Washington and Alaska rural healthcare providers who treated American Indians and Alaska Native people. Customizing presentation content to providers' educational needs encouraged attendance. Evaluation indicated videoconferencing technology was positively received for delivery of the educational sessions. This series demonstrated videoconferencing was a satisfactory means of delivering real-time, interactive cancer educational programming to providers who might not otherwise have access to such programs.

Objective: The purpose of this study was to explore the experience of cancer pain in American Indians (AI) from the Northern Plains region of the United States., Design: This was a qualitative descriptive study., Setting: Southeastern Montana., Participants: The sample consisted of 10 participants from Northern Plains AI tribes/nations, aged 31-75 years, with both solid and hematologic malignancies., Main Outcome Measures: Data were produced through semi-structured interviews and through the use of the Brief Pain Inventory-Short Form., Results: Participants reported mild-to-moderate pain on a daily basis, and pain negatively interfered with their daily activities and enjoyment of life. The average pain score at the time of interview was 4.2 out of 10. Participants described both somatic and neuropathic pain. Participants reported psychosocial distress through feelings of guilt, depression, and isolation related to their cancer, and they relied strongly on prayer and traditional medicine in coping with pain. Dominant themes were 'Isolating Within' and 'Making Connections'., Conclusions: This study suggests that there is very little difference between AI and other cultural groups regarding cancer pain in the description of pain, patterns, and types of pain management. However, this study identified notable differences in the high degree of isolation reported by AI, their desire to endure pain with stoicism, their intense desire to protect their privacy, and their distrust of outsiders. Findings from this study will inform future research on pain and pain interventions in AI patients with cancer., (Copyright © 2010 John Wiley & Sons, Ltd.)

Background: As breast cancer screening is critical to early detection and treatment, it is imperative to furnish health care providers with effective educational materials for the populations they serve. To do so for Comanche American Indian women requires understanding the cultural constructs that influence the use of screening and treatment recommendations., Purpose: The purpose of this article is to describe the health-illness beliefs and barriers to breast health for a group of Comanche women., Design: This was a descriptive, qualitative study guided by the principles of community-based participatory research. Seven community health representatives serving Comanche women participated in a "Talking Circle," an indigenous method of making decisions and conducting group process among American Indian people., Findings: Themes were Barriers to Information, Barriers to Screening, Economic Barriers, Barriers to Follow-up, and Protecting Our Women., Discussion: This study provided insight into barriers to breast health for women in the Comanche Nation. These findings contribute to a foundation for enhancements needed to make breast health education and interventions culturally appropriate. These findings also add to the cultural knowledge of nurses for use in the practice area to improve understanding and communication with American Indian patients.

In 1886, the U.S. government took the last of the free Chiricahua Apaches captive, closing the chapter on the Indian Wars in the United States. Emily Haozous, a descendent of those original captives, describes her circuitous path back to New Mexico as part of her own journey through academic nursing 110 year later.