Pre-Pandemic and Recent Oral and Medical Health Care Utilization among Young American Indian Children and Their Caregivers.

Children from diverse ethnic groups are at significantly increased risk for dental caries. In particular, American Indian (AI) children have the highest incidence of detal caries of any ethnic group. The COVID-19 pandemic dramatically restricted health care access, including preventive oral health care. Given this context, it is unclear whether or not preventive oral health care for AI children has resumed since lockdown. To address this question, we surveyed adult AI caregivers (N = 152) of children aged 0-5 years, assessing recent (12-month) and pre-COVID (for caregivers of children aged 3-5 years) preventive oral and medical health services. We also examined medical health care access and utilization among caregivers. Among children aged 3-5 years old, both pre-pandemic and past year medical care utilization were generally high (80 and 90%, respectively) as was any oral health care utilization (64 & 78%, respectively). Oral health check-ups were more common over the last year (62%) compared to pre-COVID (44%). Recent health care utilization among children 1-5 years old in this sample were generally comparable to national estimates, except for higher reported preventive medical care (99% vs. 87.6%, respectively) and higher preventive oral care (96% vs. 59.6%, respectively). More caregivers reported delaying or foregoing needed health care due to COVID (28-38%) versus due to cost (8-17%). In this survey of AI caregivers, recent child preventive health care utilization was high, and changes in utilization following the lockdown phases of the pandemic were comparable for oral and medical health care.

Formative Research and Cultural Tailoring of a Substance Abuse Prevention Program for American Indian Youth: Findings From the Intertribal Talking Circle Intervention.

Background. Substance use among American Indians (AIs) is a critical health issue and accounts for many health problems such as chronic liver disease, cirrhosis, behavioral health conditions, homicide, suicide, and motor vehicle accidents. In 2013, the highest rates of substance use and dependence were seen among AIs when compared to all other population groups, although these rates vary across different tribes. Among AI adolescents, high rates of substance use have been associated with environmental and historical factors, including poverty, historical trauma, bicultural stress, and changing tribal/familial roles. Our project, the Intertribal Talking Circle intervention, involved adapting, tailoring, implementing, and evaluating an existing intervention for AI youth of three tribal communities in the United States. Formative Results. Community partnership committees (CPCs) identified alcohol, marijuana, and prescription medications as high priority substances. CPC concerns focused on the increasing substance use in their communities and the corresponding negative impacts on families, stating a lack of coping skills, positive role models, and hope for the future as concerns for youth. Cultural Tailoring Process Results. Each site formed a CPC that culturally tailored the intervention for their tribal community. This included translating Keetoowah-Cherokee language, cultural practices, and symbolism into the local tribal customs for relevance. The CPCs were essential for incorporating local context and perceived concerns around AI adolescent substance use. These results may be helpful to other tribal communities developing/implementing substance use prevention interventions for AI youth. It is critical that Indigenous cultures and local context be factored into such programs.

US trends in mask wearing during the COVID-19 pandemic depend on rurality.

INTRODUCTION: Face masks are widely recommended as a COVID-19 prevention strategy. State mask mandates have generally reduced the spread of the disease, but decisions to wear a mask depend on many factors. Recent increases in case rates in rural areas following initial outbreaks in more densely populated areas highlight the need to focus on prevention and education. Messaging about disease risk has faced challenges in rural areas in the past. While surges in cases within some communities are likely an impetus for behavior change, rising case rates likely explain only part of mask-wearing decisions. The current study examined the relationship between county-level indicators of rurality and mask wearing in the USA. METHODS: National data from the New York Times' COVID-19 cross-sectional mask survey was used to identify the percentage of a county's residents who reported always/frequently wearing a mask (2-14 July 2020). The New York Times' COVID-19 data repository was used to calculate county-level daily case rates for the 2 weeks preceding the mask survey (15 June - 1 July 2020), and defined county rurality using the Index of Relative Rurality (n=3103 counties). Multivariate linear regression was used to predict mask wearing across levels of rurality. The model was adjusted for daily case rates and other relevant county-level confounders, including county-level indicators of age, race/ethnicity, gender, political partisanship, income inequality, and whether each county was subject to a statewide mask mandate. RESULTS: Large clusters of counties with high rurality and low mask wearing were observed in the Midwest, upper Midwest, and mountainous West. Holding daily case rates and other county characteristics constant, the predicted probability of wearing a mask decreased significantly as counties became more rural (β=-0.560; p<0.0001). CONCLUSION: Upticks in COVID-19 cases and deaths in rural areas are expected to continue, and localized outbreaks will likely occur indefinitely. The present findings highlight the need to better understand the mechanisms underlying perceptions of COVID-19 risk in rural areas. Dissemination of scientifically correct and consistent information is critical during national emergencies.

Racial/Ethnic Differences in Drug- and Alcohol-Related Arrest Outcomes in a Southwest County From 2009 to 2018.

Objectives. To estimate the association between race/ethnicity and drug- and alcohol-related arrest outcomes.Methods. We used multinomial logistic regression and general estimating equations to estimate the association between race/ethnicity and arrest outcomes in 36 073 drug- and alcohol-related arrests obtained from administrative records in a Southwest US county from 2009 to 2018. Results were stratified by charge type.Results. Among misdemeanor drug- and alcohol-related arrests, American Indian/Alaska Native (AI/AN; adjusted odds ratio [AOR] = 3.60; 95% confidence interval [CI] = 3.32, 3.90), Latino (AOR = 1.53; 95% CI = 1.35, 1.73), and Black persons (AOR = 1.28; 95% CI = 1.05, 1.55) were more likely than White persons to be booked into jail as opposed to cited and released. AI/AN (AOR = 10.77; 95% CI = 9.40, 12.35), Latino (AOR = 2.63; 95% CI = 2.12, 3.28), and Black persons (AOR = 1.84; 95% CI = 1.19, 2.84) also were more likely than White persons to be convicted and serve time for their misdemeanor charges. Results were similar for felony drug- and alcohol-related arrests aggregated and stratified.Conclusions. Our results suggest that race/ethnicity is associated with outcomes in drug-related arrests and that overrepresentation of racial/ethnic minorities in the criminal justice system cannot be attributed to greater use of drugs and alcohol in general.

Epidemiology of Incarceration: Characterizing Jail Incarceration for Public Health Research.

BACKGROUND: Each year, 9 million individuals cycle in and out of jails. The under-characterization of incarceration as an exposure poses substantial challenges to understanding how varying levels of exposure to jail may affect health. Thus, we characterized levels of jail incarceration including recidivism, number of incarcerations, total and average number of days incarcerated, and time to reincarceration. METHODS: We created a cohort of 75,203 individuals incarcerated at the Coconino County Detention Facility in Flagstaff, Arizona, from 2001 to 2018 from jail intake and release records. RESULTS: The median number of incarcerations during the study period was one (interquartile range [IQR] = 1-2). Forty percent of individuals had >1 incarceration. The median length of stay for first observed incarcerations was 1 day (IQR = 0-5). The median total days incarcerated was 3 (IQR = 1-23). Average length of stay increased by number of incarcerations. By 18 months, 27% of our sample had been reincarcerated. CONCLUSION: Characteristics of jail incarceration have been largely left out of public health research. A better understanding of jail incarcerations can help design analyses to assess health outcomes of individuals incarcerated in jail. Our study is an early step in shaping an understanding of jail incarceration as an exposure for future epidemiologic research. See video abstract at, http://links.lww.com/EDE/B536.

The Unmet Health Care Needs of Indigenous People Incarcerated in Tribal Jails.

This Viewpoint investigates the poor quality of health care provided to Indigenous peoples incarcerated in US tribal jails and proposes solutions to address health disparities and strengthen tribal sovereignty.

A formative assessment of client characteristics associated with missed appointments in integrated primary care services in rural Arizona.

INTRODUCTION: Integrating primary care services in mental healthcare facilities is an uncommon model of care in the United States that could bring several benefits (e.g., improved access to physical healthcare) for vulnerable populations experiencing mental health conditions, especially those living in underserved regions like rural Arizona. AIM: This formative assessment aimed to understand the sociodemographic and clinical characteristics of clients accessing integrated primary care (IPC) services implemented in 2021 at a community mental healthcare facility in rural Arizona and to explore the proportion of missed appointments. Additionally, we analysed the association between client characteristics and IPC missed appointments. METHODS: The authors collaborated with a community mental health facility in rural Arizona, which provided deidentified data from 280 clients who accessed IPC services from June 2021 to February 2022. RESULTS: Most clients were White and of vulnerable socioeconomic status, with a substantial proportion of Native Americans (23.58%). The majority of clients (55.75%) had a mental health disorder (MHD), 23.74% had a substance use disorder (SUD), and 15.10% had comorbid MHD and SUD. Linear regression revealed that experiencing comorbid MHD and SUD was significantly associated with missed appointments. Compared with White clients, Native Americans missed fewer appointments. CONCLUSION: Future studies conducted from a culturally-centred perspective are crucial to guide strategies to reduce missed appointments in rural IPC services.

Client perspectives on primary care integration in a rural-serving behavioral health center.

Purpose: Advancing behavioral health and primary care integration is a priority for helping clients overcome the complex health challenges impacting healthcare deserts like those in Arizona, United States of America (USA). This study aimed to explore the perspectives of people with a substance use disorder (SUD) on accessing integrated primary care (IPC) services in a rural-serving behavioral healthcare organization in Arizona. Design/methodology/approach: Clients from a behavioral health facility in Arizona (n = 10) diagnosed with SUDs who also accessed IPC participated in a 45-min semi-structured interview. Findings: The authors identified six overarching themes: (1) importance of IPC for clients being treated for SUDs, (2) client low level of awareness of IPC availability at the facility, (3) strategies to increase awareness of IPC availability at the behavioral health facility, (4) cultural practices providers should consider in care integration, (5) attitudes and perceptions about the experience of accessing IPC and (6) challenges to attending IPC appointments. The authors also identified subthemes for most of the main themes. Originality/value: This is the first study in rural Arizona to identify valuable insights into the experiences of people with SUDs accessing IPC, providing a foundation for future research in the region on care integration.

Understanding Resilience and Mental Well-Being in Southwest Indigenous Nations and the Impact of COVID-19: Protocol for a Multimethods Study.

BACKGROUND: Despite experiencing many adversities, American Indian and Alaska Native populations have demonstrated tremendous resilience during the COVID-19 pandemic, drawing upon Indigenous determinants of health (IDOH) and Indigenous Nation Building. OBJECTIVE: Our multidisciplinary team undertook this study to achieve two aims: (1) to determine the role of IDOH in tribal government policy and action that supports Indigenous mental health and well-being and, in turn, resilience during the COVID-19 crisis and (2) to document the impact of IDOH on Indigenous mental health, well-being, and resilience of 4 community groups, specifically first responders, educators, traditional knowledge holders and practitioners, and members of the substance use recovery community, working in or near 3 Native nations in Arizona. METHODS: To guide this study, we developed a conceptual framework based on IDOH, Indigenous Nation Building, and concepts of Indigenous mental well-being and resilience. The research process was guided by the Collective benefit, Authority to control, Responsibility, Ethics (CARE) principles for Indigenous Data Governance to honor tribal and data sovereignty. Data were collected through a multimethods research design, including interviews, talking circles, asset mapping, and coding of executive orders. Special attention was placed on the assets and culturally, socially, and geographically distinct features of each Native nation and the communities within them. Our study was unique in that our research team consisted predominantly of Indigenous scholars and community researchers representing at least 8 tribal communities and nations in the United States. The members of the team, regardless of whether they identified themselves as Indigenous or non-Indigenous, have many collective years of experience working with Indigenous Peoples, which ensures that the approach is culturally respectful and appropriate. RESULTS: The number of participants enrolled in this study was 105 adults, with 92 individuals interviewed and 13 individuals engaged in 4 talking circles. Because of time constraints, the team elected to host talking circles with only 1 nation, with participants ranging from 2 to 6 in each group. Currently, we are in the process of conducting a qualitative analysis of the transcribed narratives from interviews, talking circles, and executive orders. These processes and outcomes will be described in future studies. CONCLUSIONS: This community-engaged study lays the groundwork for future studies addressing Indigenous mental health, well-being, and resilience. Findings from this study will be shared through presentations and publications with larger Indigenous and non-Indigenous audiences, including local recovery groups, treatment centers, and individuals in recovery; K-12 and higher education educators and administrators; directors of first responder agencies; traditional medicine practitioners; and elected community leaders. The findings will also be used to produce well-being and resilience education materials, in-service training sessions, and future recommendations for stakeholder organizations. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/44727.

Between Two Worlds: Impacts of COVID-19 on the AI/AN Health Research Workforce.

The COVID-19 pandemic has had devastating global and national impacts including major loss of life, economic downturns, and ongoing impairments to mental and physical health. Conducting health research has remained a priority and has helped mitigate some of the COVID-19 devastation; however, challenges to research have arisen due to COVID-19 prevention strategies and changing community priorities for research. The purpose of this article is to focus on a critical piece of the health research process with American Indian and Alaska Native (AI/AN) communities and the AI/AN health research workforce. Throughout this editorial, we provide challenges faced while conducting research with AI/AN communities during the COVID-19 pandemic including changes to research processes and ongoing research studies, taking on multiple roles in academic spaces, and mourning for continuous community loss while continuing to conduct research that may benefit AI/AN communities. Using a strengths-based lens, we also provide examples of flexibility, adaptation, and resilience in the face of the ongoing COVID-19 pandemic.

Changes in sleep quality and housing status among individuals incarcerated in jail.

OBJECTIVE: To investigate sleep quality among individuals incarcerated in a rural county jail, by housing status before incarceration. METHODS: Using cross-sectional survey methods, 194 individuals incarcerated in jail reported sleep quality prior to and during incarceration on a Likert scale and pre-incarceration housing status (ie, house, apartment, motel, group living, or homeless). Prevalence ratios (PR) were estimated using log binomial regression to determine associations between housing status before incarceration and changes in sleep quality. RESULTS: Participants in non-permanent housing before incarceration had a lower prevalence of worsening sleep quality while incarcerated (compared to stable or improving) compared to those in permanent housing before incarceration (PR = 1.69, 95% CI: 1.03, 2.77). CONCLUSIONS: Pre-incarceration housing is associated with change in sleep quality among individuals incarcerated in jail. Jail may be an important point of intervention to improve sleep quality during incarceration and through connecting individuals to more stable living conditions.

Nutrition availability for those incarcerated in jail: Implications for mental health.

PURPOSE: Using a seven-day cycle menu and commissary items at a rural county jail, this study aims to describe provisions of micronutrients known to be associated with mental health disorders and if they meet dietary guidelines. DESIGN/METHODOLOGY/APPROACH: The nutritional content of a seven-day cycle menu and four available commissary food packs were evaluated using NutritionCalc® Plus software (McGraw-Hill Education version 5.0.19) and compared to Dietary Reference Intakes (DRI). FINDINGS: Menu mean values of Vitamin B6, Vitamin B12, Vitamin C and zinc met DRI recommendations. However, Vitamin D (for men and women), magnesium (for men only) and omega-3s (for men only) did not meet the DRI recommendations. ORIGINALITY/VALUE: As deficits of Vitamin D, magnesium and omega-3s are known to exacerbate bipolar disorder, anxiety and depression, small changes to food would increase the offerings and potential intake of nutrients that may improve mental health.

Community based participatory research approaches to combat oral health inequities among American Indian and Alaska Native populations.

American Indian and Alaska Native (AI/AN) communities have experienced a history of systemic racism and still face significant oral health disparities. These disparities extend to the youngest community members in the form of early childhood caries (ECC). Although behavior and biology contribute to ECC, the conditions where people live, grow, and work, and the systems and political and economic forces that shape individual health outcomes, are thought to greatly impact ECC among AI/AN populations. To address ECC in AI/AN communities, we used a community based participatory approach that incorporated social determinants of health. We found that implementing culturally-tailored, culturally-centered, and AI/AN-created materials for ECC interventions is viewed favorably by community members and tribal leaders. Because of the complexity of ECC in AI/AN communities we adopted a bundled approach of best practices to reduce ECC including: (1) incorporating locally, contextually, and culturally relevant strategies to present recommended ECC prevention approaches; (2) employing AI/AN community members as educators; (3) utilizing motivational interviewing with expectant mothers; and (4) providing fluoride varnish. Our work underscores the importance of developing trusting partnerships with each other and with our communities, drawing upon the insights of community advisory board members, and eliciting formative assessment data from tribal members to gain a more holistic understanding of our participants' lived experience to design relevant intervention materials. Incorporating local knowledge and situating Western oral health prevention approaches within culturally aligned frameworks can enhance partnerships and create sustainable materials for community work.

A Formative Assessment of Social Determinants of Health Related to Early Childhood Caries in Two American Indian Communities.

In the United States, children from diverse ethnic groups and those with low socioeconomic status are at a significantly increased risk for early childhood caries. Despite the efforts focused on decreasing early childhood caries in American Indian (AI) populations, these children have the highest incidence of dental caries of any ethnic group, with four times the cases of untreated dental caries compared to white children. This qualitative formative assessment was conducted in two AI communities. Semi-structured interviews (n = 57) were conducted with caregivers and providers to understand the social and community contexts in which oral health behaviors and practices occur from the perspective of the caregivers, oral health care providers, and social service providers in the communities. The analysis was informed by the social determinants of health framework. The key social determinants of pediatric oral health relevant to our study communities included limited access to: oral health promoting nutritious foods, transportation for oral health appointments, and pediatric specialty care. This formative assessment provided locally and contextually relevant information to shape the development of an oral health clinical trial intervention to address early childhood caries in these two communities.

Adverse Childhood Events in American Indian/Alaska Native Populations.

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

Health disparities in jail populations: Mixed methods and multi-disciplinary community engagement for justice and health impacts.

This special issue of Practicing Anthropology presents multidisciplinary and multisectoral views of a community engaged health disparities project titled "Health Disparities in Jail Populations: Converging Epidemics of Infectious Disease, Chronic Illness, Behavioral Health, and Substance Abuse." The overall project incorporated traditional anthropological mixed-methods approaches with theory and methods from informatics, epidemiology, genomics, evolutionary and computational biology, community engagement, and applied/translational science.

A Survey of Health Disparities, Social Determinants of Health, and Converging Morbidities in a County Jail: A Cultural-Ecological Assessment of Health Conditions in Jail Populations.

The environmental health status of jail populations in the United States constitutes a significant public health threat for prisoners and the general population. The ecology of jails creates a dynamic condition in relation to general population health due to the concentrated potential exposure to infectious diseases, difficult access to treatment for chronic health conditions, interruption in continuity of care for serious behavioral health conditions, as well as on-going issues for the prevention and treatment of substance abuse disorders. This paper reports on elements of a cross-sectional survey embedded in a parent project, "Health Disparities in Jail Populations." The overall project includes a comprehensive secondary data analysis of the health status of county jail populations, along with primary data collection that includes a cross-sectional health and health care services survey of incarcerated individuals, coupled with collection of biological samples to investigate infectious disease characteristics of a county jail population. This paper reports on the primary results of the survey data collection that indicate that this is a population with complex and interacting co-morbidities, as well as significant health disparities compared to the general population.