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Background and Objectives With the rate of Alzheimer's disease and related dementias (ADRD) increasing among Alaska Indian/Alaska Native (AI/AN) people, the Alaska Native Health system is ill-prepared to meet the challenges associated with the growing population at risk of ADRD. The high cost of care, inadequate training of health care providers, and lack of supportive services for caregivers are especially concerning. Research Design and Methods Interviews were conducted with 22 AN caregivers for ANs with ADRD and 12 ANs and non-Native health care providers in communities across Alaska. Interviews lasted approximately 60 min and were transcribed verbatim. We employed directed content analysis to examine the major agreements and disagreements between the participants' understandings of ADRD in each of the domains of Kleinman's Explanatory Model of Illness. Results Caregivers and health care providers expressed concerns about the lack of understanding, resources, and awareness of ADRD among ANs in rural and urban communities. Both caregivers and providers recognized the need to obtain an early diagnosis, blend Western and traditional medicines, promote lifestyle and dietary changes, and foster training for caregivers. Health care providers acknowledged their limited exposure to AN understanding of ADRD and wish to receive culturally relevant training to better serve AN. Discussion and Implications As the older AN adult population grows, the need for culturally responsive training and support services will continue to increase. We recommend establishing rural outreach and support groups for caregivers, developing an understanding of how ANs view ADRD to train and educate health care providers, and implement screening early for memory loss during routine medical examinations. [ABSTRACT FROM AUTHOR]

This special issue on Promoting Health Equity through Rigorous, Culturally Informed Intervention Science: Innovations with Indigenous Populations in the United States is a welcome addition to the growing recognition that culture is fundamental to effective intervention design, implementation, and research, in this instance among Indigenous peoples of North America and the Pacific. The articles herein summarize some of the priorities, findings, and lessons learned through work conducted by researchers in the National Institutes of Health Intervention Research to Improve Native American Health (IRINAH) consortium. The lessons learned encourage rethinking of the epistemological imperatives of our science; recognizing the rich, important variation in the lived experience of Indigenous peoples; and a greater appreciation for the critical role this experience plays in conceptualizing, designing, and operationalizing effective interventions. In this regard, the authors return us to a nearly 3 decades' old, but largely unrealized commitment by the National Institutes of Health to the thoughtful inclusion of underrepresented racial and ethnic minorities in its sponsored research as a means of improving the clinical and implementation sciences. The findings summarized in this special issue demonstrate the value of such efforts and fit well within existing paradigms that emphasize the importance of culture for maximizing the relevance and impact of this work. Yet the remaining challenge is to promote this agenda in ways that invite others to contribute in equally deliberate and informed ways, and thereby advance the field at large. [ABSTRACT FROM AUTHOR]

Background/Objectives Methods Results Conclusions The Skindex‐29 and Skindex‐Teen assess dermatology‐related quality of life among adults and adolescents, respectively. This study directly compared the same adolescents' responses to the Skindex‐29 relative to Skindex‐Teen in a predominantly American Indian and/or Alaska Native population. This population is underrepresented in medical research. Although skin‐related quality‐of‐life issues are widespread, American Indian and/or Alaska Native adolescents are not well‐represented in related studies.Data were collected in‐person by self‐report survey at two regional powwows in Denver, Colorado in 2021 and 2022. Respondents completed the full Skindex‐29 and Skindex‐Teen (40 unique items total).Eighty‐six adolescents, 12–17 years old, completed the survey. The majority (70.9%, 61/86) of respondents self‐identified as American Indian and/or Alaska Native. Analyses were conducted with all respondent survey data. Nearly two‐thirds (64.0%, 55/86) of our respondents had a Skindex‐29 score that revealed their quality of life was impaired at least mildly by skin disease. The Skindex‐29 and Skindex‐Teen demonstrated good reliability; there was substantial concordance between responses to the two measures (r values ranged from 0.88 to 0.97 for similar subscales). Compared to younger adolescents (aged 12–14), older adolescents (aged 15–17) reported worse dermatology‐related quality of life and emotional toll based on higher Skindex‐29 total, Skindex‐Teen total, Skindex‐29 Emotional subscale, and Skindex‐Teen Psychosocial Functioning subscale scores.American Indian and/or Alaska Native adolescents suffer from skin‐related quality‐of‐life issues. The Skindex‐Teen and Skindex‐29 generated similar information regarding quality of life in young patients with skin disease. While the Skindex‐Teen may be slightly more relevant to adolescents, these surveys were highly concordant. Both the Skindex‐Teen and Skindex‐29 exhibited frequent “never” responses to questions about impact of skin conditions on relationships with others and tendencies to stay home. Thus, careful attention should be paid to such questions to ensure their relevance to adolescents. [ABSTRACT FROM AUTHOR]

The association of psychosocial factors (psychological distress, coping skills, family support, trauma exposure, and spirituality) with initial weight and weight loss among American Indians and Alaska Natives (AI/ANs) in a diabetes prevention translational project was investigated. Participants (n=3,135) were confirmed as prediabetic and subsequently enrolled in the Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) demonstration project implemented at 36 Indian health care programs. Measures were obtained at baseline and after completing a 16-session educational curriculum focusing on weight loss through behavioral changes. At baseline, psychological distress and negative family support were linked to greater weight, whereas cultural spirituality was correlated with lower weight. Furthermore, psychological distress and negative family support predicted less weight loss, and positive family support predicted greater weight loss, over the course of the intervention. These bivariate relationships between psychosocial factors and weight remained statistically significant within a multivariate model, after controlling for sociodemographic characteristics. Conversely, coping skills and trauma exposure were not significantly associated with baseline weight or change in weight. These findings demonstrate the influence of psychosocial factors on weight loss in AI/AN communities and have substantial implications for incorporating adjunctive intervention components. [ABSTRACT FROM AUTHOR]

The association of psychosocial factors (psychological distress, coping skills, family support, trauma exposure, and spirituality) with initial weight and weight loss among American Indians and Alaska Natives (AI/ANs) in a diabetes prevention translational project was investigated. Participants (n=3,135) were confirmed as prediabetic and subsequently enrolled in the Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) demonstration project implemented at 36 Indian health care programs. Measures were obtained at baseline and after completing a 16-session educational curriculum focusing on weight loss through behavioral changes. At baseline, psychological distress and negative family support were linked to greater weight, whereas cultural spirituality was correlated with lower weight. Furthermore, psychological distress and negative family support predicted less weight loss, and positive family support predicted greater weight loss, over the course of the intervention. These bivariate relationships between psychosocial factors and weight remained statistically significant within a multivariate model, after controlling for sociodemographic characteristics. Conversely, coping skills and trauma exposure were not significantly associated with baseline weight or change in weight. These findings demonstrate the influence of psychosocial factors on weight loss in AI/AN communities and have substantial implications for incorporating adjunctive intervention components. [ABSTRACT FROM AUTHOR]

This paper is the second in a five-part series on the clinical and translational science educational pipeline. It focuses on the role that Clinical and Translational Science Award (CTSA) programs can play in supporting science, technology, engineering, and math (STEM) education in primary and secondary schools, as well as in facilitating these interests during transition to undergraduate training. Special emphasis should be placed on helping to form and sustain an identity as a scientist, and on instilling the persistence necessary to overcome numerous barriers to its actualization. CTSAs can contribute to cementing this sense of self by facilitating peer support, mentorship, and family involvement that will reinforce early educational decisions leading to clinical and translational science research careers. Meanwhile, the interests, skills, and motivation induced by participation in STEM programs must be sustained in transition to the next level in the educational pipeline, typically undergraduate study. Examples of CTSA collaborations with local schools, businesses, interest groups, and communities at large illustrate the emerging possibilities and promising directions with respect to each of these challenges. [ABSTRACT FROM AUTHOR]

Posttraumatic stress disorder (PTSD) has been found to be more common among American Indian populations than among other Americans. A complex diagnosis, the assessment methods for PTSD have varied across epidemiological studies, especially in terms of the trauma criteria. Here, we examined data from the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP) to estimate the lifetime prevalence of PTSD in two culturally distinct American Indian reservation communities, using two formulas for calculating PTSD prevalence. The AI-SUPERPFP was a cross-sectional probability sample survey conducted between 1997 and 2000. Southwest ( n = 1,446) and Northern Plains ( n = 1,638) tribal members living on or near their reservations, aged 15-57 years at time of interview, were randomly sampled from tribal rolls. PTSD estimates were derived based on both the single worst and 3 worst traumas. Prevalence estimates varied by ascertainment method: single worst trauma (lifetime: 5.9% to 14.8%) versus 3 worst traumas (lifetime, 8.9% to 19.5%). Use of the 3-worst-event approach increased prevalence by 28.3% over the single-event method. PTSD was prevalent in these tribal communities. These results also serve to underscore the need to better understand the implications for PTSD prevalence with the current focus on a single worst event. [ABSTRACT FROM AUTHOR]

Objective: The landmark Diabetes Prevention Program (DPP) showed that lifestyle intervention can prevent or delay the onset of diabetes for those at risk. We evaluated a translational implementation of this intervention in a diverse set of American Indian and Alaska Native (AI/AN) communities.Research Design and Methods: The Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) demonstration project implemented the DPP lifestyle intervention among 36 health care programs serving 80 tribes. A total of 2,553 participants with prediabetes were recruited and started intervention by 31 July 2008. They were offered the 16-session Lifestyle Balance Curriculum and underwent a thorough clinical assessment for evaluation of their diabetes status and risk at baseline, soon after completing the curriculum (postcurriculum), and annually for up to 3 years. Diabetes incidence was estimated. Weight loss, changes in blood pressure and lipid levels, and lifestyle changes after intervention were also evaluated.Results: The completion rates of SDPI-DP were 74, 59, 42, and 33% for the postcurriculum and year 1, 2, and 3 assessments, respectively. The crude incidence of diabetes among SDPI-DP participants was 4.0% per year. Significant improvements in weight, blood pressure, and lipid levels were observed immediately after the intervention and annually thereafter for 3 years. Class attendance strongly correlated with diabetes incidence rate, weight loss, and change in systolic blood pressure.Conclusions: Our findings demonstrate the feasibility and potential of translating the lifestyle intervention in diverse AI/AN communities. They have important implications for future dissemination and institutionalization of the intervention throughout the Native American health system. [ABSTRACT FROM AUTHOR]

OBJECTIVE--The landmark Diabetes Prevention Program (DPP) showed that lifestyle intervention can prevent or delay the onset of diabetes for those at risk. We evaluated a translational implementation of this intervention in a diverse set of American Indian and Alaska Native (AI/ AN) communities. RESEARCH DESIGN AND METHODS--The Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) demonstration project implemented the DPP lifestyle intervention among 36 health care programs serving 80 tribes. A total of 2,553 participants with prediabetes were recruited and started intervention by 31 July 2008. They were offered the 16-session Lifestyle Balance Curriculum and underwent a thorough clinical assessment for evaluation of their diabetes status and risk at baseline, soon after completing the curriculum (postcurriculum), and annually for up to 3 years. Diabetes incidence was estimated. Weight loss, changes in blood pressure and lipid levels, and lifestyle changes after intervention were also evaluated. RESULTS--The completion rates of SDPI-DP were 74, 59, 42, and 33% for the postcurriculum and year 1, 2, and 3 assessments, respectively. The crude incidence of diabetes among SDPI-DP participants was 4.0% per year. Significant improvements in weight, blood pressure, and lipid levels were observed immediately after the intervention and annually thereafter for 3 years. Class attendance strongly correlated with diabetes incidence rate, weight loss, and change in systolic blood pressure. CONCLUSIONS--Our findings demonstrate the feasibility and potential of translating the lifestyle intervention in diverse AI/AN communities. They have important implications for future dissemination and institutionalization of the intervention throughout the Native American health system. [ABSTRACT FROM AUTHOR]

AbstractObjective:Mental health issues are a serious concern for many American Indian Veterans, especially for post-traumatic stress disorder and related psychiatric conditions. Yet, acquiring mental health treatment can be a challenge in Native communities where specialized services are largely unavailable. Consequently, telehealth is increasingly being suggested as a way to expand healthcare access on or near reservation lands. In this study, we wanted to understand the factors affecting the diffusion of telehealth clinics that provided mental health care to rural, American Indian Veterans.Materials and Methods:We surveyed 39 key personnel and stakeholders who were involved in the decision-making process, technological infrastructure, and implementation of three clinics. Using Roger Everett'sDiffusion Theory as a framework, we gathered information about specific tasks, factors hindering progress, and personal reactions to telehealth both before and after implementation.Results:Many participants expressed initial concerns about using telehealth; however, most became positive over time. Factors that influenced participants' viewpoint largely included patient and staff feedback and witnessing the fulfillment of a community health need. The use of outside information to support the implementation of the clinics and personal champions also showed considerable influence in the clinics' success.Conclusion:The findings presented here address critical gaps in our understanding of telehealth diffusion and inform research strategies regarding the cultural issues and outcomes related to telemental health services. Information contained in this report serves as a long overdue guide for developing telemental health programs and policies among American Indians, specifically, and rural populations in general. [ABSTRACT FROM AUTHOR]

Persistence in a research career can be readily understood within the trainee models that have emerged from undergraduate and graduate instruction. These models offer a common language for discussing training processes, serve as guides for assessing trainee needs, promise to render training programs that are more comprehensive and attentive than are current programs to the factors that contribute to academic and scientific persistence, and enable us to measure with greater precision, internal consistency, and generalizability the elements that logically belong in research career development programs. (Am J Public Health. 2009;99:S20-S25. [ABSTRACT FROM AUTHOR]

Objective: This study examines the association of cultural participation and social engagement with self-reported diagnosis of memory problems among older American Indians and Alaska Natives (AI/ANs). Method: We conducted a cross-sectional study of 14,827 AI/ANs using data from the 2014–2017 cycle of the Identifying Our Needs: A Survey of Elders (ION). Logistic regression was used to examine the association of cultural participation and social engagement with self-reported diagnosis of memory problems. Results: Compared to older AI/ANs who reported high cultural participation and/or high social engagement, those characterized by low cultural participation and/or low social engagement exhibited significantly higher odds of a self-reported diagnosis of memory problems (OR = 1.863, 95% CI: [1.269, 2.734], p =.001). Discussion: Older AI/ANs who described either or both low cultural participation and low social engagement endorsed far more self-reported diagnoses of memory problems, suggesting a strong association that warrants further study for potential causality. [ABSTRACT FROM AUTHOR]

Objectives : To describe recent advances in our knowledge regarding the health and illness of older American Indians and Alaska Natives, and factors underlying why this special population lives 5.5 years less than the 78.5 years of U.S. all races. Methods : The articles in this supplemental issue, authored by participants in a National Institutes of Health-sponsored early research career development program, examine high priority health concerns that contribute to the increased risk of Native elders for chronic disease and resulting impairment that compromise their life expectancy. Results : Important insights into the roles that racial discrimination, food security, hypertension, alcohol consumption, memory problems, and military service play in the health and well-being of older American Indians and Alaska Natives. Discussion : Early career faculty development programs focused on increasing the diversity of the scientific workforce not only promote greater racial and ethnic minority representation in the field of aging, but can simultaneously add to the knowledge base regarding the health status and function of often ignored, vulnerable older members of communities that suffer significant health disparities. [ABSTRACT FROM AUTHOR]

The demand for evidence-based health practices has created a cultural challenge for Indigenous people around the world. This paper reports on the history and evolution of evidence-based care into its mainstream status within the behavioural health field. Through the leadership of an Alaska Native tribal organisation, an international forum was convened to address the challenges of evidence-based practice for Indigenous people. Forum participants developed a model for gathering evidence that integrates rigorous research with Indigenous knowledge and values. The model facilitates development of practices and programmes that are culturally congruent for Indigenous people, accepted and validated by the research community, and deemed supportable by private and governmental sponsors. [ABSTRACT FROM AUTHOR]

The quality, relevance, timeliness, and impact of public health research among American Indians and Alaska Natives (AIAN) has improved markedly over the last several decades. These advances are attributable to the more careful fit between investigative methods and field exigencies, to the increased presence of Native scientists among research teams, to greater emphasis on meaningful collaboration between researchers and participating communities, and to new Federal investments in the infrastructure that supports health research within this special population. This paper describes the lessons learned from this recent progress, and highlights opportunities to promote further gains as well as continuing needs in developing our capacity to conduct policy relevant AIAN health research. [ABSTRACT FROM AUTHOR]

The development and dissemination of culturally relevant health care information has traditionally taken a "top-down" approach. Governmental funding agencies and research institutions have too often dictated the importance and focus of health-related research and information dissemination. In addition, the digital divide has affected rural communities in such a way that their members often do not possess the knowledge or experience necessary to use technological resources. And, even when they do, their skills may be limited, adequate only for implementing applications and programs designed by others who live and work outside of these communities. This need became the driving force in the creation of the Native Telehealth Outreach and Technical Assistance Program. The goal of the program is to equip Native community members, at both the lay and professional levels, with the means to use technology to address tribal health care needs. The transfer of relevant technical knowledge and skills enables participants to develop projects which enhance the community-wide dissemination of health care information. Nine community health advocates and professionals participated in the initial cohort. Eight of the participants successfully developed multimedia-based projects including Web sites, interactive CD-ROMs, and video focusing on a variety of health concerns. At the conclusion of the 18-month program period, projects were disseminated throughout rural communities. The NTOTAP staff continues to evaluate the use of these projects and their benefits within the rural communities. [ABSTRACT FROM AUTHOR]

Objective: Residents' cognitive, psychiatric, and behavioral statuses were examined as part of a larger study of care in a nursing home (NH) owned and operated by a Northern Plains American Indian tribe. Method: Reviews of 45 medical records and semistructured interviews with 36 staff were completed. Results: Creekside residents had considerable psychiatric and behavioral morbidity. High prevalences of non-Alzheimer's disease dementia, cognitive impairment, anxious symptomatology, and resistance to care were met with psychopharmacotherapy, reorientation+ and informal techniques for behavior management. Significant depressive, anxious, psychotic, and behavioral symptoms remained. Staff interpretations of resident problems consisted of an ethnopsychological schema emphasizing resident loneliness, grumpiness, and propensity to "fight" rather than formal psychiatric nosology. Discussion: Tribal NH residents were likely underdiagnosed for dementia and anxiety. Residual behavioral and psychiatric symptomatology suggest room for improvement in the NH's behavioral management regimen. Need for greater attention to conceptual, diagnostic, clinical, and documentation processes in the NH setting is noted. [ABSTRACT FROM AUTHOR]

This study examined the relationship between severe traumatic events and alcohol use disorders in American Indian adolescents and young adults. Interviews of 432 adolescents and young adults who were enrolled tribal members living on or near two closely related American Indian reservations were used. Results indicated that severe trauma increased the odds of alcohol use disorders (p <.001), with the number of traumas having a dose-dependent effect. The authors conclude that trauma is associated with alcohol use disorders in this population. This study's findings yield important insights into the risks in American Indian adolescents and young adults that may result from early trauma, as well as implications for the timing and possible settings for intervention. [ABSTRACT FROM AUTHOR]

Objective: American Indian populations have often been considered to be at greater risk for major depressive episode than are other groups in the United States. The American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP), completed between 1997 and 1999, was designed to allow comparisons with the baseline National Comorbidity Survey (NCS), conducted in 1990-1992. The prevalence of lifetime and 12-month DSM-III-R major depressive episode was compared between the Al-SUPERPFP and NCS samples. Method: A total of 3,084 tribal members (1,446 in a Southwest tribe [73.7% of eligible participants] and 1,638 in a Northern Plains tribe [76.8% of eligible participants]) age 15-54 years living on or near their home reservations were interviewed. An adaptation of the University of Michigan Composite International Diagnostic Interview and the NCS algorithm for diagnosis were used to estimate the prevalence of lifetime and 12-month major depressive episode in these groups. Results: The prevalence estimates for life-time and 12-month major depressive episode were substantially lower in the American Indian samples, compared to the NCS sample. Detailed analyses indicated differential endorsement of lifetime symptoms between the American Indian groups and the NCS participants. Furthermore, American Indians were substantially less likely than NCS participants to indicate that depressive symptoms had co-occurred during an episode lasting at least 2 weeks. The lifetime prevalence estimates based on the NCS algorithm ranged from 3.8% to 7.9% for men and women in the two tribes. The analogous rates based on an adapted Al-SUPERPEP algorithm ranged from 7.2% and 14.3%. Few tribe, age, and gender differences were found. Conclusions: The findings underscore the need for careful examination of diagnostic instruments cross-culturally. Adaptation of the NCS algorithm for diagnosis appears necessary for estimation of the prevalence of major depressive episode in the American Indian populations included in this study. In striving to better reflect the clinical diagnostic process in epidemiological and services research, careful consideration of the resulting complexity becomes increasingly critical. [ABSTRACT FROM AUTHOR]

Objectives. We examined the prevalence of trauma in 2 large American Indian communities in an attempt to describe demographic correlates and to compare findings with a representative sample of the US population. Methods. We determined differences in exposure to each of 16 types of trauma among 3084 tribal members aged 15 to 57 years through structured interviews. We compared prevalence rates of trauma, by gender, across the 2 tribes and with a sample of the US general population. We used logistic regression analyses to examine the relationships of demographic correlates to trauma exposure. Results. Lifetime exposure rates to at least 1 trauma (62.4%-67.2% among male participants, 66.2%-69.8% among female participants) fell at the upper limits of the range reported by other researchers. Unlike the US general population, female and male American Indians exhibited equivalent levels of overall trauma exposure. Members of both tribes more often witnessed traumatic events, experienced traumas to loved ones, and were victims of physical attacks than their counterparts in the overall US population. Conclusions. American Indians live in adverse environments that place them at high risk for exposure to trauma and harmful health sequelae. [ABSTRACT FROM AUTHOR]

Objective: To illustrate successful strategies in working with American Indian (AI) and Alaska Native (AN) communities in aging and health research by emphasizing access, local relevance, and decision-making processes. Methods: Case examples of health studies involving older AIs (≥50 years) among Eastern Band Cherokee Indians, a federally recognized reservation; the Cherokee Nation, a rural, nonreservation, tribal jurisdictional service area; and Lakota tribal members living in Rapid City, South Dakota. Results: Local review and decision making reflect the unique legal and historical factors underpinning AI sovereignty. Although specific approval procedures vary, there are common expectations across these communities that can be anticipated in conceptualizing, designing, and implementing health research among native elders. Conclusions: Most investigators are unprepared to address the demands of health research in AI communities. Community-based participatory research in this setting conflicts with investigators' desire for academic freedom and scientific independence. Successful collaboration promises to enhance research efficiencies and move findings more quickly to clinical practice. [ABSTRACT FROM AUTHOR]

Presents a case study of posttraumatic stress disorder in an American Indian veteran. Medical history and cultural identity of the veteran; Significance of cultural influences on the disorder; Cultural factors that contributed to the psychosocial environment of the patient.

The August 2001 issuance of Mental Health: Culture, Race, and Ethnicity--A Supplement to Mental Health: A Report of the Surgeon General, represents a landmark in the dialogue--political and scientific--regarding health disparities in the United States. This paper offers a critical appraisal of the process and structure of generating these reports, paying particular attention to issues that marked serious epistemological tensions among the participants. These issues revolved around the relative emphasis placed on (1) mental illness and mental health; (2) risk, etiology, and treatment versus prevention and promotion; (3) large-scale, population-based surveys and randomized clinical trials as the standard bearers of scientific evidence; (4) variation related to gender, social class, and culture; (5) ethnicity and culture as dispositional variables or individual glosses as opposed to dynamic, collective phenomena; and (6) the historical forces that shaped the contemporary context for much of this discussion. It describes the sometimes subtle, other times stark differences in assumptions and experience that sprang from disciplinary orientations, investigative methods, institutional affiliations, and personal histories and agendas. [ABSTRACT FROM AUTHOR]

Increasingly, the mental health needs of populations are measured using large-sample surveys with standardized measures and methods. Such efforts, however, rarely include sufficient number of smaller, culturally defined populations to draw defensible conclusions about their needs. Furthermore, without some adaptation, the standardized methods and measures may yield invalid results in such populations. Using a recently completed psychiatric epidemiology and services study with American Indian populations as a case example, this paper outlines issues facing epidemiologists working in such culturally diverse contexts. The issues discussed include the following: (1) persuading the scientific community and potential sponsors that work with distinct or culturally defined populations is important; (2) framing research questions and activities to meet the needs of communities; (3) defining a population of inference; (4) balancing the needs for comparability and cultural specificity; (5) maximizing scientific validity in light of the challenges in sample acquisition; and (6) developing and implementing data collection methods that uphold scientific standards but are also realistic given the context. The authors draw on their experiences--most recently in the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP)--to illustrate these issues and suggest ways to address each. A goal of this paper is to challenge those invested in conducting culturally valid epidemiologic work in such populations to better articulate the nature of these efforts. [ABSTRACT FROM AUTHOR]

This study employed data from two Congressionally mandated efforts (the American Indian Vietnam Veterans Project and the National Vietnam Veterans Readjustment Study) to examine differential prevalence of posttraumatic stress disorder (PTSD) among 5 ethnically defined samples of male Vietnam theater veterans. Lay interviews assessed individual experiences before, during, and after the war from 1,798 male Vietnam theater veterans. Clinical reinterviews using the SCID were conducted with subsamples (N = 487). The prevalence of both 1-month and lifetime PTSD was higher for the 2 American Indian samples than for Whites. Once logistic regressions controlled for differential exposure to war-zone stress, ethnicity was no longer a significant predictor of PTSD. [ABSTRACT FROM AUTHOR]

This special review summarizes and illustrates the state of our knowledge regarding the mental health needs of American Indians and Alaska Natives. These needs are considerable and pervasive. The discussion begins by reflecting on the limits of psychiatric nomenclature and conceptual frameworks for revealing Native constructions of mental health and mental illness. The experience and manifestation of psychopathology can be both different and the same across cultures, hinging upon the extent to which such basic assumptions as the relationship of mind to body--and spirit in the case of Native people--or the primacy of the individual or social collective are shared. Having set the stage, this paper moves to recent empirical evidence regarding the mental health needs of American Indians and Alaska Natives: we review that evidence and consider it within the broader context of available services. The report closes with a brief overview of the most pressing issues and forces for change afoot in Indian country in the US. Most have to do with the structure and financing of care as tribes and other Native community-based organizations seek to balance self-determination and resource management to arrive at effective, fiscally responsible, culturally informed prevention, treatment, and aftercare options for their members. These changes may herald similar trends among First Nations people to the immediate north. [ABSTRACT FROM AUTHOR]

Background: Sleep impairment may be a key pathway through which discrimination undermines health. Links between discrimination and sleep in American Indians and Alaska Natives (AI/AN) have not been established. Further, it is unclear if such links might depend on the timing of discrimination or if socioeconomic status (SES) might buffer the impact of discrimination.Purpose: To investigate associations between interpersonal discrimination and sleep impairment in urban AI/AN, for both lifetime and recent discrimination, and controlling for other life stressors. Education and income, indices of SES, were tested as potential moderators.Methods: A community sample of urban AI/AN (N = 303, 18-78 years old, 63% female) completed self-report measures of sleep impairment, lifetime and recent discrimination, depressive symptoms, perceived stress, other life stressors (childhood adversity and past year major events), and socio-demographic characteristics.Results: Lifetime discrimination was associated with impaired sleep in AI/AN after adjustment for socio-demographic characteristics, recent depressive symptoms, perceived stress, and other life stressors. Past-week discrimination was associated with sleep in unadjusted but not adjusted models. Education, but not income, was found to buffer the effects of both lifetime and past-week discrimination on sleep in adjusted models.Conclusion: Lifetime discrimination uniquely accounts for sleep impairment and may be especially harmful in those with less education. These findings suggest targeting interventions to those most in need. Limitations include the cross-sectional nature of the data. Longitudinal and qualitative work is needed to understand how education may buffer the effects of discrimination on sleep and perhaps other health problems in AI/AN. [ABSTRACT FROM AUTHOR]

American Indian and Alaska Native (Native) Veterans enrolled in the U.S. Department of Veterans Affairs (VA) benefits program are far less likely to access health care compared to other racial/ethnic groups, in part driven by challenges posed by often distant, complex, and culturally unresponsive health care that does not easily interface with the Indian Health Service (IHS) and local Tribal Health Care. To address this disparity, in 2020 the Veteran's Health Administration's (VHA) Office of Rural Health (ORH) initiated the development of a patient navigation program designed specifically for rural Native Veterans. There are no navigation programs for rural Native Veterans to guide development of such a program. Hence, the project team sought perspectives from rural Native Veterans, their families, and community advocates, (n = 34), via video and phone interviews about the role and functions of a Veteran patient navigator and personal characteristics best be suited for such a position. Participants believed a navigator program would be useful in assisting rural Native Veterans to access VHA care. They emphasized the importance of empathy, support, knowledge of local culture, and of Veteran experience within tribal communities, adeptness with VHA systems, and personnel consistency. These insights are critical to create a program capable of increasing rural Native Veteran access to VHA services. [ABSTRACT FROM AUTHOR]

Comments on the article `Primary Prevention Mental Health Programs for Children and Adolescents: A Meta-analytic Review,' written by Joseph A. Durlak and Anne M. Wells. Significance of the article; Distinction between mental health promotion and illness prevention; Details on the article's contents.

Describes chronic fatigue syndrome as a common complaint in ambulatory settings. Characterization of chronic fatigue syndrome; Determination of the differences that exist between Caucasian and minority patients with CF; Reference to the Medical Outcomes Study Short-Forum Health Survey; Description of fatigue; Medical evaluation of CF patients.

Presents a description of a domestic violence program in an urban Indian health care. Failure of office-based interventions; Importance of developing interventions.

Highlights some of the important issues for researchers seeking to include American Indians and Alaska Natives in clinical research in the United States. Defining the population of American Indians and Alaska Natives; Confidentiality and anonymity of individuals and tribes; Identification of potential benefits of American Indian and Alaska Native communities.

Presents a case study of an Indian male suffering from post-traumatic stress disorder and its relation to a culturally-based therapy through an all-Indian support group. Presentation of the case with focus on the patient's history, analysis of the causes of the illness, cultural factors and past treatments; Assessment of the healing process.

Focuses on the assessment of psychopathology in American Indian and Alaska Native children and adolescents. Social contexts and cultural forces that shape an Indian child's everyday world; Cultural variation in the phenomenology of psychiatric syndromes; Limitations of current diagnostic problems.

Examines the association of psychosocial constructs with the quantity and frequency of alcohol consumption in a Native American boarding school. Boarding school adolescents as heavy drinkers; Associations among depression, familial support, stressful life events and alcohol use.

Background: Food insecurity is an important social determinant of health that was exacerbated by the COVID-19 pandemic. Both food insecurity and COVID-19 infection disproportionately affect racial and ethnic minority groups, particularly American Indian and Alaska Native communities; however, there is little evidence as to whether food insecurity is associated with COVID-19 infection or COVID-19 preventive behaviors such as vaccination uptake. The purpose of this study was to evaluate associations between food insecurity, COVID-19 infection, and vaccination status among urban American Indian and Alaska Native adults seen at 5 clinics serving urban Native people. Methods: In partnership with health organizations in Alaska, Colorado, Kansas, Minnesota, and New Mexico, the study team conducted a cross-sectional survey in 2021 to assess food security status and attitudes, barriers, and facilitators for COVID-19 testing and vaccination. Logistic regression was used to examine the association of food security status with sociodemographic factors and COVID-19 infection and vaccination status. Marginal standardization was applied to present results as prevalence differences. Results: Among 730 American Indian and Alaska Native adults, the prevalence of food insecurity measured during the pandemic was 38%. For participants who reported persistent food security status before and during the pandemic (n = 588), the prevalence of food insecurity was 25%. Prevalence of COVID-19 infection and vaccination did not vary by food security status after adjustment for confounders. Conclusions: High rates of food insecurity among American Indian and Alaska Native communities likely increased during the COVID-19 pandemic. However, despite the high prevalence of food insecurity, community-led efforts to reduce COVID-19 infection and increase vaccination uptake across Indian Health Service and Tribal healthcare facilities may have mitigated the negative impacts of the pandemic for families experiencing food insecurity. These successful approaches serve as an important reference for future public health efforts that require innovative strategies to improve overall health in American Indian and Alaska Native communities. [ABSTRACT FROM AUTHOR]

Objective: To provide a research agenda and recommendations to address inequities in access to health care. Data Sources and Study Setting: The Agency for Healthcare Research and Quality (AHRQ) organized a Health Equity Summit in July 2022 to evaluate what equity in access to health care means in the context of AHRQ's mission and health care delivery implementation portfolio. The findings are a result of this Summit, and subsequent convenings of experts on access and equity from academia, industry, and the government. Study Design: Multi‐stakeholder input from AHRQ's Health Equity Summit, author consensus on a framework and key knowledge gaps, and summary of evidence from the supporting literature in the context of the framework ensure comprehensive recommendations. Data Collection/Extraction Methods: Through a stakeholder‐engaged process, themes were developed to conceptualize access with a lens toward health equity. A working group researched the most appropriate framework for access to care to classify limitations identified during the Summit and develop recommendations supported by research in the context of the framework. This strategy was intentional, as the literature on inequities in access to care may itself be biased. Principal Findings: The Levesque et al. framework, which incorporates multiple dimensions of access (approachability, acceptability, availability, accommodation, affordability, and appropriateness), is the backdrop for framing research priorities for AHRQ. However, addressing inequities in access cannot be done without considering the roles of racism and intersectionality. Recommendations include funding research that not only measures racism within health care but also tests burgeoning anti‐racist practices (e.g., co‐production, provider training, holistic review, discrimination reporting, etc.), acting as a convener and thought leader in synthesizing best practices to mitigate racism, and forging the path forward for research on equity and access. Conclusions: AHRQ is well‐positioned to develop an action plan, strategically fund it, and convene stakeholders across the health care spectrum to employ these recommendations. [ABSTRACT FROM AUTHOR]

Interactive voice response and text message (IVR-T) technology may improve hypertension control in under-resourced settings. We conducted a randomized clinical trial to determine whether an IVR-T intervention would improve blood pressure (BP), medication adherence and visit keeping among adults with hypertension from multiple racial and ethnic groups in primary care at an Urban Indian Health Organization in Albuquerque, New Mexico. Two hundred and ninety-five participants were randomly assigned to IVR-T (N = 148) or to usual care (N = 147). The IVR-T arm received reminders for clinic visits, messages to reschedule missed clinic visits, monthly medication refill reminders, weekly motivational messages, and a blood pressure cuff. The usual care arm received no messages. The primary outcome was change in systolic BP (SBP) between baseline and 12 months. Secondary outcomes included change in SBP between baseline and 6 months, change in diastolic BP (DBP) at 6 and 12 months, self-reported adherence at 6 months, and the proportion of missed primary care clinic appointments. The intervention did not affect SBP or DBP at 6 or 12 months. The 12-month change in SBP/DBP was 1.66/1.10 mm Hg in usual care and 0.23/1.34 mm Hg in the intervention group (P values = .57 and .88, respectively). Self-reported medication adherence improved comparably in both groups, and there was no difference in percentage of kept visits. Several features of study design, clinic operations, and data transfer were barriers to demonstrating effectiveness. [ABSTRACT FROM AUTHOR]

A response to a commentary on the authors' article on the Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) demonstration project(2) is presented. They explain the aim of the SDPI-DP to show the feasibility and impact of translating a proven intervention into a variety of American Indian and Alaska Native communities. They also compare the eligibility criteria used by the SDPI-DP and the Diabetes Prevention Program (DPP).

The article focuses on the occurrence of type 1 diabetes (T1D) and type 2 diabetes (T2D) among American Indian and Alaska Native (AI/AN) populations in 2012–2013, highlighting notably higher T2D rates across age groups. It mentions regional disparities within Indian Health Service (IHS) areas, emphasizing the imperative for tailored interventions to address diabetes disparities in AI/AN communities.

OBJECTIVE: To examine HbA1c levels and adherence to oral glucose-lowering medications and their association with future HbA1c levels among American Indian adults with type 2 diabetes (T2D) receiving medications at no cost from a tribal health care system. RESEARCH DESIGN AND METHODS: Tribal citizens with T2D who used Choctaw Nation Health Services Authority (CNHSA) and Pharmacies and had HbA1c data during 2017–2018 were included in this study. Medication adherence (proportion of days covered [PDC] ≥0.80) was calculated using 2017 CNHSA electronic health record data. RESULTS: Of the 74,000 tribal citizens living on tribal lands, 4,560 were eligible; 32% had HbA1c at or below target (≤7%), 36% were above target (>7 to ≤9%), and 32% were uncontrolled (>9%) in 2017. The percentage of patients with PDC ≥0.80 was 66% for those using biguanides, 72% for sulfonylureas, 75% for dipeptidyl peptidase 4 inhibitors, and 83% for sodium–glucose cotransporter 2 inhibitors. The proportion of patients with HbA1c at or below target increased slightly from 32% in 2017 to 42% in 2018. Higher average PDC in 2017 was associated with lower HbA1c levels in 2018 (β = −1.143; P < 0.001). CONCLUSIONS: Medication adherence was higher than that found in previous studies using self-report methods in American Indian populations, although a smaller proportion of patients had HbA1c at or below target relative to U.S. adults with T2D. Medication adherence was associated with improved HbA1c levels for most oral glucose-lowering medication classes. Future studies of American Indians should use both longitudinal prescription data from both electronic health records and pharmacy refills. [ABSTRACT FROM AUTHOR]

Objectives: To examine the relationships between pre-pregnancy diabetes mellitus (DM), gestational diabetes mellitus (GDM), pre-pregnancy body mass index (BMI) and county-level social determinants of health, with infant macrosomia within a sample of American Indian/Alaska Native (AI/AN) women receiving Indian Health Service (IHS) care. Methods: The sample included women-infant dyads representing 1,136 singleton births from fiscal year 2011 (10/1/2019-9/30/2011). Data stemmed from the IHS Improving Health Care Delivery Data Project. Multivariate generalized linear mixed models were fitted to assess the association of macrosomia with pre-pregnancy health status and social determinants of health. Results: Nearly half of the women in the sample were under age 25 years (48.6%), and most had Medicaid health insurance coverage (76.7%). Of those with a pre-pregnancy BMI measure, 66.2% were overweight or obese. Although few women had pre-pregnancy DM (4.0%), GDM was present in 12.8% of women. Most women had a normal term delivery (85.4%). Overweight, obesity, pre-pregnancy DM, and county-level rurality were all significantly associated with higher odds of infant macrosomia. [ABSTRACT FROM AUTHOR]

Purpose: This study examined the associations between participant and site characteristics and retention in a multisite cardiovascular disease risk reduction project. Design and Methods: Data were derived from the Special Diabetes Program for Indians Healthy Heart Demonstration Project, an intervention to reduce cardiovascular risk among American Indians and Alaska Natives with diabetes. In 2006, a total of 1,072 participants from 30 participating sites completed baseline questionnaires measuring demographics and sociobehavioral factors. They also underwent a medical examination at baseline and were reassessed annually after baseline. A Provider Annual Questionnaire was administered to staff members of each grantee site at the end of each year to assess site characteristics. Generalized estimating equation models were used to evaluate the relationships between participant and site characteristics and retention 1 year after baseline. Results: Among enrolled participants, 792 (74%) completed their first annual assessment. Participants who completed the first annual assessment tended to be older and had, at baseline, higher body mass index and higher level of physical activity. Site characteristics associated with retention included average age of staff, proportion of female staff members, and percentage of staff members having completed graduate or professional school. Implications: Understanding successful retention must reach beyond individual characteristics of participants to include features of the settings that house the interventions. [ABSTRACT FROM PUBLISHER]

Background and Objectives: A "revolving door" of repeated admissions to detoxification treatment facilities has long plagued alcohol and drug use patients, yet few studies examine factors associated with readmission. This study examined risk factors for readmission to alcohol and opioid detoxification in a sample from the Alaska Interior. Methods: Data were extracted from electronic medical records for admissions between 2012 and 2016 at an inpatient detoxification facility in Fairbanks, Alaska. Data from 1014 patients admitted for alcohol detoxification and 267 patients admitted for opioid detoxification were analyzed. The analysis employed descriptive statistics for risk factors (substance use history, adverse life experiences, and psychosocial functioning) and prevalence of readmission to either alcohol or opioid detoxification. Inferential analyses used marginal standardization to calculate differences in readmission risk by patient characteristics. Results: Male, Alaska Native/American Indian, single‐never married patients, and those seeking work were at higher risk for readmission to alcohol detoxification, while those with stable housing were at reduced risk. Being single‐never married and completing detoxification treatment reduced readmission to opioid detoxification. Family involvement in detoxification reduced readmission risk for both alcohol and opioid patients. Discussion and Conclusions: Further research that investigates the mechanism(s) by which family may act as a protective factor may be efficacious in eliminating the "revolving door" of detoxification. Scientific Significance: This study is the first to examine both alcohol and opioid use risk and protective factors in the Alaska Interior. The results can be used in the development of interventions for subpopulations with high detoxification readmission rates. [ABSTRACT FROM AUTHOR]

Objective: American Indian and Alaska Native peoples (AI/ANs) have a disproportionately high rate of obesity, but little is known about the social determinants of obesity among older AI/ANs. Thus, our study assessed social determinants of obesity in AI/ANs aged ≥ 50 years.Design: We conducted a cross-sectional analysis using multivariate generalized linear mixed models to identify social determinants associated with the risk of being classified as obese (BMI ≥ 30.0 kg/m2). Analyses were conducted for the total study population and stratified by median county poverty level.Setting: Indian Health Service (IHS) data for AI/ANs who used IHS services in FY2013.Participants: 27,696 AI/ANs aged ≥ 50 years without diabetes.Results: Mean BMI was 29.8 ± 6.6 with 43% classified as obese. Women were more likely to be obese than men, and younger ages were associated with higher obesity risk. While having Medicaid coverage was associated with lower odds of obesity, private health insurance was associated with higher odds. Living in areas with lower rates of educational attainment and longer drive times to primary care services were associated with higher odds of obesity. Those who lived in a county where a larger percentage of people had low access to a grocery store were significantly less likely to be obese.Conclusions: Our findings contribute to the understanding of social determinants of obesity among older AI/ANs and highlight the need to investigate AI/AN obesity, including longitudinal studies with a life course perspective to further examine social determinants of obesity in older AI/ANs. [ABSTRACT FROM AUTHOR]