Prevalence and Indicators of Household Smoking Bans Among American Indians.

More than 58 million nonsmokers in the U.S. encounter secondhand smoke that leads to tobacco-related diseases and deaths every year, making voluntary household smoking bans an important public health goal. American Indians/Alaska Natives are rarely included in research related to household smoking bans. Further, most studies dichotomize household smoking bans into complete bans versus partial/no bans, rendering it impossible to determine if partial and no bans are associated with different or similar risk factors. Using the 2014 Cherokee Nation American Indian Adult Tobacco Survey, our study sought to identify prevalence of household smoking bans, their extent, and their correlates in an American Indian population. This cross-sectional analysis used multinomial logistic regression to determine correlates of complete, partial, and no household smoking bans. Results indicated that approximately 84% of Cherokee households have a complete ban. Younger age, female gender, higher education, higher household income, respondent's nonsmoking status, good health, better awareness of harms related to secondhand smoke, visits with a healthcare provider within the past year, and children in the home were positively and significantly associated with complete household smoking bans. Additionally, there were notable differences between correlates related to partial bans and no bans. These results provide insight for the development of more appropriate interventions for American Indian households that do not have a complete household smoking ban.

Low-level inorganic arsenic exposure and neuropsychological functioning in American Indian elders.

BACKGROUND: Inorganic arsenic at high and prolonged doses is highly neurotoxic. Few studies have evaluated whether long-term, low-level arsenic exposure is associated with neuropsychological functioning in adults. OBJECTIVES: To investigate the association between long-term, low-level inorganic arsenic exposure and neuropsychological functioning among American Indians aged 64-95. METHODS: We assessed 928 participants in the Strong Heart Study by using data on arsenic species in urine samples collected at baseline (1989-1991) and results of standardized tests of global cognition, executive functioning, verbal learning and memory, fine motor functioning, and speed of mental processing administered during comprehensive follow-up evaluations in 2009-2013. We calculated the difference in neuropsychological functioning for a 10% increase in urinary arsenic with adjustment for sex, age, education, and study site. RESULTS: The sum of inorganic and methylated arsenic species (∑As) in urine was associated with limited fine motor functioning and processing speed. A 10% increase in ∑As was associated with a .10 (95% CI -.20, -.01) decrease on the Finger Tapping Test for the dominant hand and a .13 decrease (95% CI -.21, -.04) for the non-dominant hand. Similarly, a 10% increase in ∑As was associated with a .15 (95% CI -.29, .00) decrease on the Wechsler Adult Intelligence Scale-Fourth Edition Coding Subtest. ∑As was not associated with other neuropsychological functions. CONCLUSIONS: Findings indicate an adverse association between increased urinary arsenic fine motor functioning and processing speed, but not with other neuropsychological functioning, among elderly American Indians.

Health Literacy and Informed Consent Materials: Designed for Documentation, Not Comprehension of Health Research.

Minority populations with health disparities are underrepresented in research designed to address those disparities. One way to improve minority representation is to use community-based participatory methods to overcome barriers to research participation, beginning with the informed consent process. Relevant barriers to participation include lack of individual or community awareness or acceptance of research processes and purposes. These barriers are associated with limited health literacy. To inform recommendations for an improved consent process, we examined 97 consent documents and 10 associated Institutional Review Board websites to determine their health literacy demands and degree of adherence to principles of community-based research. We assessed the reading level of consent documents and obtained global measures of their health literacy demand by using the Suitability and Comprehensibility Assessment of Materials instrument. Although these documents were deemed suitable as medical forms, their readability levels were inappropriate, and they were unsuitable for educating potential participants about research purposes. We also assessed consent forms and Institutional Review Board policies for endorsement of community-based participatory principles, finding that very few acknowledged or adhered to such principles. To improve comprehension of consent documents, we recommend restructuring them as educational materials that adhere to current health literacy guidelines.

Transdisciplinary cardiovascular and cancer health disparities training: experiences of the centers for population health and health disparities.

The Centers for Population Health and Health Disparities program promotes multilevel and multifactorial health equity research and the building of research teams that are transdisciplinary. We summarized 5 areas of scientific training for empowering the next generation of health disparities investigators with research methods and skills that are needed to solve disparities and inequalities in cancer and cardiovascular disease. These areas include social epidemiology, multilevel modeling, health care systems or health care delivery, community-based participatory research, and implementation science. We reviewed the acquisition of the skill sets described in the training components; these skill sets will position trainees to become leaders capable of effecting significant change because they provide tools that can be used to address the complexities of issues that promote health disparities.

Cultural identity and patient trust among older American Indians.

BACKGROUND: Patients' trust in healthcare providers and institutions has been identified as a likely contributor to racial-ethnic health disparities. The likely influence of patients' cultural characteristics on trust is widely acknowledged but inadequately explored. OBJECTIVE: To compare levels of patients' trust in primary care provider (interpersonal trust) with trust in healthcare organizations (institutional trust) among older American Indians (AIs), and determine associations with cultural identity. DESIGN: Patient survey administered following primary care visits. PARTICIPANTS: Two-hundred and nineteen American Indian patients ≥ 50 years receiving care for a non-acute condition at two clinics operated by the Cherokee Nation in northeastern Oklahoma. MAIN MEASURES: Self-reported sociodemographic and cultural characteristics. Trust was measured using three questions about interpersonal trust and one measure of institutional trust; responses ranged from strongly agree to strongly disagree. Finding substantial variation only in institutional trust, we used logistic generalized estimating equations to examine relationships of patient cultural identity with institutional trust. KEY RESULTS: Ninety-five percent of patients reported trusting their individual provider, while only 46 % reported trusting their healthcare institution. Patients who strongly self-identified with an AI cultural identity had significantly lower institutional trust compared to those self-identifying less strongly (OR: 0.6, 95 % CI: 0.4, 0.9). CONCLUSIONS: Interpersonal and institutional trust represent distinct dimensions of patients' experience of care that may show important relationships to patients' cultural characteristics. Strategies for addressing low institutional trust may have special relevance for patients who identify strongly with AI culture.

Association of American Indian cultural identity with physical activity.

OBJECTIVE: Cultural factors are associated with health behaviors among American Indians. Accordingly, the objective of our study was to investigate whether cultural identity, defined as the primary language spoken at home, is associated with: 1) higher total physical activity levels, and 2) levels of leisure-time physical activity recommended for health benefits in a diverse sample of American Indians. DESIGN: Cross-sectional analysis of 5,207 American Indian adults 18 to 82 years. Participants resided on the Oglala Sioux (n=2,025) and Cheyenne River Sioux (n=1,528) reservations in South Dakota, and the Gila River Indian Community (n=1,654) in Arizona. RESULTS: Bicultural participants in South Dakota, but not Arizona, reported significantly higher total physical activity compared to the English-only group (P<.05). About 35% of English only speakers, 39% of American Indian/Alaska Native only speakers, and 39% of participants speaking both languages met the 150 minutes/week activity threshold. Odds of being sufficiently active were higher among bicultural respondents in both regions when compared to respondents endorsing only English, controlling for sociodemographic and health-related covariates (P<.05). CONCLUSION: Bicultural respondents among tribal members in South Dakota had significantly higher total physical activity, and higher levels of sufficient leisure-time activity in both South Dakota and Arizona, compared to those who spoke either language exclusively. Interventions that encourage American Indians to develop their bicultural efficacy and to draw on resources for healthy living that may be available in all the cultures with which they identify are recommended.

Religio-Spiritual Participation in Two American Indian Populations.

Following a previous investigation of religio-spiritual beliefs in American Indians, this article examined prevalence and correlates of religio-spiritual participation in two tribes in the Southwest and Northern Plains (N = 3,084). Analysis suggested a "religious profile" characterized by strong participation across three traditions: aboriginal, Christian, and Native American Church. However, sociodemographic variables that have reliably predicted participation in the general American population, notably gender and age, frequently failed to achieve significance in multivariate analyses for each tradition. Religio-spiritual participation was strongly and significantly related to belief salience for all traditions. Findings suggest that correlates of religious participation may be unique among American Indians, consistent with their distinctive religious profile. Results promise to inform researchers' efforts to understand and theorize about religio-spiritual behavior. They also provide tribal communities with practical information that might assist them in harnessing social networks to confront collective challenges through community-based participatory research collaborations.

Trauma and conditional risk of posttraumatic stress disorder in two American Indian reservation communities.

PURPOSE: To determine conditional risk of posttraumatic stress disorder (PTSD) in two culturally distinct American Indian reservation communities. METHOD: Data derived from the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project, a cross-sectional population-based survey that was completed between 1997 and 2000. This study focused on 1,967 participants meeting the DSM-IV criteria for trauma exposure. Traumas were grouped into interpersonal, non-interpersonal, witnessed, and "trauma to close others" categories. Analyses examined distribution of worst traumas, conditional rates of PTSD following exposure, and distributions of PTSD cases deriving from these events. Bivariate and multivariate logistic regressions estimated associations of lifetime PTSD with trauma type. RESULTS: Overall, 15.9 % of those exposed to DSM-IV trauma qualified for lifetime PTSD, a rate comparable to similar US studies. Women were more likely to develop PTSD than were men. The majority (60 %) of cases of PTSD among women derived from interpersonal trauma exposure (in particular, sexual and physical abuse); among men, cases were more evenly distributed across trauma categories. CONCLUSIONS: Previous research has demonstrated higher rates of both trauma exposure and PTSD in American Indian samples compared to other Americans. This study shows that conditional rates of PTSD are similar to those reported elsewhere, suggesting that the elevated prevalence of this disorder in American Indian populations is largely due to higher rates of trauma exposure.

Culture and colorectal cancer screening on three American Indian reservations.

BACKGROUND: Colorectal cancer (CRC) rates among many American Indian populations are high. Screening by fecal occult blood test (FOBT) and endoscopy is effective for reducing CRC mortality, but little research has examined the extent of such screening in reservation populations. Further, nothing is known of how American Indians' cultural characteristics may be related to screening receipt. PARTICIPANTS AND SETTING: We examined data from participants recruited from 2 Northern Plains and 1 Southwest reservation for the Education and Research Toward Health (EARTH) study. All participants aged > or = 51 years were eligible for inclusion. DESIGN: After calculating screening rates, we examined bivariate relationships between screening and participant characteristics, including measures of cultural characteristics including ethnic identity and use of traditional healing practices. We applied multivariate regression to relate these cultural variables to odds of lifetime screening by FOBT or endoscopy. RESULTS: Of 751 American Indians sampled, 35% reported lifetime CRC screening by at least one modality. Multivariate analyses did not reveal significant relationships or trends relating FOBT to respondents' cultural characteristics. By contrast, odds of endoscopy were significantly lower among persons who spoke a tribal language at home (OR .6, 95% C.I. .4-.9), and trend analysis revealed an inverse relationship between endoscopy and number of identity measures endorsed (Ptrend<.1). CONCLUSIONS: The sampled population exhibits disparities in CRC compared to the general population, and cultural characteristics are related to odds of endoscopy. Findings warrant culturally tailored CRC screening initiatives for American Indians.

Perceived cancer risk among American Indians: implications for intervention research.

OBJECTIVE: Perceived risk of disease plays a key role in health behaviors, making it an important issue for cancer-prevention research. We investigate associations between perceived cancer risk and selected cancer risk factors in a population-based sample of American Indians. STUDY DESIGN AND POPULATION: Data for this cross-sectional study come from a random sample of 182 American Indian adults, aged > or = 40 years, residing on the Hopi Reservation in northeastern Arizona. OUTCOME MEASURES: Perception of cancer risk was ascertained with the 5-point Likert scale question, "How likely do you think it is that you will develop cancer in the future?" dichotomized into low perceived risk and high perceived risk. RESULTS: Participants reporting a family member with cancer were more likely, by greater than five times, to report the perception that they would get cancer (OR = 5.3; 95% CI: 2.3, 12.3). After controlling for age and family history of cancer, knowledge of cancer risk factors and attitude about cancer prevention were not significantly associated with risk perception. CONCLUSIONS: Perceived cancer risk was significantly associated with self-reported family history of cancer, supporting the importance of personal knowledge of cancer among American Indians. Further research is needed to obtain a more complete picture of the factors associated with perceptions of cancer risk among American Indians in order to develop effective interventions.

Religiosity and Spiritual Engagement in Two American Indian Populations.

Social scientific investigation into the religiospiritual characteristics of American Indians rarely includes analysis of quantitative data. After reviewing information from ethnographic and autobiographical sources, we present analyses of data from a large, population-based sample of two tribes (n = 3,084). We examine salience of belief in three traditions: aboriginal, Christian, and Native American Church. We then investigate patterns in sociodemographic subgroups, determining the significant correlates of salience with other variables controlled. Finally, we examine frequency with which respondents assign high salience to only one tradition (exclusivity) or multiple traditions (nonexclusivity), again investigating subgroup variations. This first detailed, statistical portrait of American Indian religious and spiritual lives links work on tribal ethnic identity to theoretical work on America's "religious marketplace." Results may also inform social/behavioral interventions that incorporate religiospiritual elements.

Perceptions of medical interactions between healthcare providers and American Indian older adults.

Cultural competence models assume that culture affects medical encounters, yet little research uses objective measures to examine how this may be true. Do providers and racial/ethnic minority patients interpret the same interactions similarly or differently? How might patterns of provider-patient concordance and discordance vary for patients with different cultural characteristics? We collected survey data from 115 medical visits with American Indian older adults at a clinic operated by the Cherokee Nation (in Northeastern Oklahoma, USA), asking providers and patients to evaluate nine affective and instrumental interactions. Examining data from the full sample, we found that provider and patient ratings were significantly discordant for all interactions (Wilcoxon signed-rank test p

Using PhotoVoice to Promote Land Conservation and Indigenous Well-Being in Oklahoma.

Indigenous ancestral teachings commonly present individual and community health as dependent upon relationships between human and nonhuman worlds. But how do persons conversant with ancestral teachings effectively convey such perspectives in contemporary contexts, and to what extent does the general tribal citizenry share them? Can media technology provide knowledge keepers with opportunities to communicate their perspectives to larger audiences? What are the implications for tribal citizens' knowledge and views about tribal land use policies? Using a PhotoVoice approach, we collaborated with a formally constituted body of Cherokee elders who supply cultural guidance to the Cherokee Nation government in Oklahoma. We compiled photographs taken by the elders and conducted interviews with them centered on the project themes of land and health. We then developed a still-image documentary highlighting these themes and surveyed 84 Cherokee citizens before and after they viewed it. Results from the pre-survey revealed areas where citizens' perspectives on tribal policy did not converge with the elders' perspectives; however, the post-survey showed statistically significant changes. We conclude that PhotoVoice is an effective method to communicate elders' perspectives, and that tribal citizens' values about tribal land use may change as they encounter these perspectives in such novel formats.

Spirituality and mental health status among Northern Plain tribes.

Spirituality measures often show positive associations with preferred mental health outcomes in the general population; however, research among American Indians (AIs) is limited. We examined the relationships of mental health status and two measures of spirituality - the Midlife Development Inventory (MIDI) and a tribal cultural spirituality measure - in Northern Plains AIs, aged 15-54 (n = 1636). While the MIDI was unassociated with mental health status, the tribal cultural spirituality measure showed a significant relationship with better mental health status. Mental health conditions disproportionately affect AIs. Understanding protective factors such as cultural spirituality that can mitigate mental health disorders is critical to reducing these health disparities.

Cultural identities and perceptions of health among health care providers and older American Indians.

BACKGROUND: Differences in provider-patient health perceptions have been associated with poor patient outcomes, but little is known about how patients' cultural identities may be related to discordant perceptions. OBJECTIVE: To examine whether health care providers and American-Indian patients disagreed on patient health status ratings, and how differences related to these patients' strength of affiliation with American-Indian and white-American cultural identities. DESIGN: Survey of patients and providers following primary care office visits. PARTICIPANTS: One hundred and fifteen patients > or =50 years and 7 health care providers at a Cherokee Nation clinic. All patients were of American-Indian race, but varied in strength of affiliation with separate measures of American-Indian and white-American cultural identities. MEASUREMENTS: Self-reported sociodemographic and cultural characteristics, and a 5-point rating of patient's health completed by both patients and providers. Fixed-effects regression modeling examined the relationships of patients' cultural identities with differences in provider-patient health rating. RESULTS: In 40% of medical visits, providers and patients rated health differently, with providers typically judging patients healthier than patients' self-rating. Provider-patient differences were greater for patients affiliating weakly with white cultural identity than for those affiliating strongly (adjusted mean difference=0.70 vs 0.12, P=.01). Differences in ratings were not associated with the separate measure of affiliation with American-Indian identity. CONCLUSIONS: American-Indian patients, especially those who affiliate weakly with white-American cultural identity, often perceive health status differently from their providers. Future research should explore sources of discordant perceptions.

Patient and Provider Factors Associated With American Indian and Alaska Native Adolescent Tobacco Use Screening.

INTRODUCTION: Tobacco use is the leading behavioral cause of death among adults 25 years or older. American Indian (AI) and Alaska Native (AN) communities confront some of the highest rates of tobacco use and of its sequelae. Primary care-based screening of adolescents is an integral step in the reduction of tobacco use, yet remains virtually unstudied. We examined whether delivery of tobacco screening in primary care visits is associated with patient and provider characteristics among AI/AN adolescents. METHODS: We used a cross-sectional analysis to examine tobacco screening among 4757 adolescent AI/AN patients served by 56 primary care providers at a large tribally managed health system between October 1, 2011 and May 31, 2014. Screening prevalence was examined in association with categorical patient characteristics (gender, age, clinic visited, insurance coverage) and provider characteristics (gender, age, tenure) using multilevel logistic regressions with individual provider identity as the nesting variable. RESULTS: Thirty-seven percent of eligible patients were screened. Gender of both providers and patients was associated with screening. Male providers delivered screening more often than female providers (odds ratio [OR] 1.6, 95% confidence interval [CI] 0.7-3.9). Male patients had 20% lower odds of screening receipt (OR 0.8, 95% CI 0.7-0.9) than female patients, independent of patient age and provider characteristics. Individual provider identity significantly contributed to variability in the mixed-effects model (variance component 2.2; 95% CI 1.4-3.4), suggesting individual provider effect. CONCLUSIONS: Low tobacco screening delivery by female providers and the low receipt of screening among younger, male patients may identify targets for screening interventions.

Patient satisfaction and ethnic identity among American Indian older adults.

Work in the field of culturally competent medical care draws on studies showing that minority Americans often report lower satisfaction with care than White Americans and recommends that providers should adapt care to patients' cultural needs. However, empirical evidence in support of cultural competence models is limited by reliance upon measurements of racial rather than ethnic identity and also by a near-total neglect of American Indians. This project explored the relationship between ethnic identity and satisfaction using survey data collected from 115 chronically ill American Indian patients >or=50 years at a Cherokee Nation clinic. Satisfaction scores were high overall and comparable to those found in the general population. Nevertheless, analysis using hierarchical linear modeling showed that patients' self-rated American Indian ethnic identity was significantly associated with satisfaction. Specifically, patients who rated themselves high on the measure of American Indian ethnic identity reported reduced scores on satisfaction with health care providers' social skill and attentiveness, as compared to those who rated themselves lower. Significant associations remained after controlling for patients' sex, age, education, marital status, self-reported health, wait time, and number of previous visits. There were no significant associations between patients' American Indian ethnic identity and satisfaction with provider's technical skill and shared decision-making. Likewise, there were no significant associations between satisfaction and a separate measure of White American ethnic identity, although a suggestive trend was observed for satisfaction with provider's social skill. Our findings demonstrate the importance of including measures of ethnic identity in studies of medical satisfaction in racial minority populations. They support the importance of adapting care to patient's cultural needs, and they highlight the particular significance of interpersonal communication for patient satisfaction among American Indians. Results will be of special interest to health researchers, clinicians, and policy makers working in fields related to minority health.

Spirituality and attempted suicide among American Indians.

American Indians exhibit suicide-related behaviors at rates much higher than the general population. This study examines the relation of spirituality to the lifetime prevalence of attempted suicide in a probability sample of American Indians. Data were derived from a cross-sectional sample of 1456 American Indian tribal members (age range 15-57yr) who were living on or near their Northern Plains reservations between 1997 and 1999. Data were collected by personal interviews. Commitment to Christianity was assessed using a measure of beliefs. Commitment to tribal cultural spirituality (or forms of spirituality deriving from traditions that predate European contact) was assessed using separate measures for beliefs and spiritual orientations. Results indicated that neither commitment to Christianity nor to cultural spirituality, as measured by beliefs, was significantly associated with suicide attempts (p(trend) for Christianity=0.22 and p(trend) for cultural spirituality=0.85). Conversely, commitment to cultural spirituality, as measured by an index of spiritual orientations, was significantly associated with a reduction in attempted suicide (p(trend)=0.01). Those with a high level of cultural spiritual orientation had a reduced prevalence of suicide compared with those with low level of cultural spiritual orientation. (OR=0.5, 95% CI=0.3, 0.9). This result persisted after simultaneous adjustment for age, gender, education, heavy alcohol use, substance abuse and psychological distress. These results are consistent with anecdotal reports suggesting the effectiveness of American Indian suicide-prevention programs emphasizing orientations related to cultural spirituality.

Access, relevance, and control in the research process: lessons from Indian country.

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 (greater than or equal to 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.

Food Insecurity and Obesity Among American Indians and Alaska Natives and Whites in California.

Food insecurity is linked to obesity among some, but not all, racial and ethnic populations. We examined the prevalence of food insecurity and the association between food insecurity and obesity among American Indians (AIs) and Alaska Natives (ANs) and a comparison group of whites. Using the 2009 California Health Interview Survey, we analyzed responses from 592 AIs/ANs and 7371 white adults with household incomes at or below 200% of the federal poverty level. Food insecurity was measured using a standard 6-item scale. Sociodemographics, exercise, and obesity were all obtained using self-reported survey data. Logistic regression was used to estimate associations. The prevalence of food insecurity was similar among AIs/ANs and whites (38.7% vs 39.3%). Food insecurity was not associated with obesity in either group in analyses adjusted for sociodemographics and exercise. The ability to afford high-quality foods is extremely limited for low-income Californians regardless of race. Health policy discussions must include increased attention on healthy food access among the poor, including AIs/ANs, for whom little data exist.