From East to West: A Narrative Review of Healthcare Models in India and the United States.

The global healthcare landscape is fraught with quality, cost, equity, and innovation challenges. Despite this, successful healthcare interventions have emerged from unexpected locations. In India, the eradication of certain communicable diseases, the expansion of access to primary care, and the implementation of innovative methods such as telemedicine have demonstrated the potential for community-centered care. In the United States (US), improvements in healthcare quality, accessibility, and the utilization of medical technology, such as the incorporation of telehealth and artificial intelligence, have highlighted opportunities for technological innovation in healthcare delivery. This manuscript reviews the history and development of healthcare systems in India and the US, highlighting each system's strengths, weaknesses, lessons learned, and opportunities for improvement. By examining both systems, we strive to promote a healthcare model that incorporates lessons from each country to improve community-centered care and ultimately provide equitable access to all.

Lessons From India: A Narrative Review of Integrating Yoga Within the US Healthcare System.

The ancient practice of yoga has gained worldwide popularity as a way for people to improve their overall health and well-being. This manuscript reviews and examines the history of yoga, its physical and mental health benefits, its incorporation into the Indian healthcare system, and the public perception of yoga in India. Many initiatives for yoga exist, including promoting research on yoga, providing education and information on its benefits, and developing evidence-based standardized yoga therapy guidelines. With this in mind, this narrative review article explores the potential benefits of incorporating yoga into the United States (US) healthcare system and the possible challenges of doing so. It also provides valuable insights for policymakers and healthcare professionals.

Patterns of Health Care Access and Use in an Urban American Indian and Alaska Native Population.

Studies of health care access and use among historically resilient populations, while common, often field a limited sample size and rarely ask the groups most impacted by health inequities to weigh in. This is especially so for research and programs that focus on the American Indian and Alaska Native (AIAN) population. The present study addresses this gap by examining data from a cross-sectional survey of AIANs in Los Angeles County. To better interpret project findings and generate culturally relevant contexts, qualitative feedback was gathered at a community forum held in Spring 2018. Because recruitment of AIANs has historically been challenging, purposive sampling was employed to strategically identify a larger eligible pool. Among those who were eligible, 94% completed the survey (n = 496). AIANs who were enrolled in a tribe were 32% more likely to use the Indian Health Service (IHS), compared with those who were not enrolled (95% CI: 20.4%, 43.2%; p < .0001). In multivariable modeling, the strongest factors influencing IHS access and use were: tribal enrollment, preference for culturally-specific health care, proximity of the services to home or work, having Medicaid, and having less than a high school education. Feedback from the community forum indicated cost and trust (of a provider) were important considerations for most AIANs. Study findings reveal heterogeneous patterns of health care access and use in this population, suggesting a need to further improve the continuity, stability, and the image of AIANs' usual sources of care (e.g., IHS, community clinics).

Behavioral health services in Urban American Indian Health Programs: Results from six site visits.

This study explores behavioral health services for American Indians and Alaska Natives (AIANs) at six Urban Indian Health Programs (UIHPs). Interviews and focus groups with clinicians and staff inquired about behavioral health treatment available, service needs, client population, and financial and staffing challenges. Resulting site profiles were created based on focused coding and integrative memoing of site visit field notes and respondent transcripts. These six UIHPs evidenced diversity across multiple facets of service delivery even as they were united in their missions to provide accessible and effective behavioral health treatment to urban AIAN clients. Primary challenges to service provision included heterogenous client populations, low insurance coverage, limited provider knowledge, lack of resources, and incorporation of traditional healing. Collaborative research with UIHPs harbors the potential to recognize challenges, identify solutions, and share best practices across this crucial network of health care sites for improving urban AIAN well-being.

Facilitating the Urgent Public Health Need to Improve Data Sharing With Tribal Epidemiology Centers.

Tribal Epidemiology Centers (TECs) are an essential and unique part of the public health system and an important part of federal efforts to improve the health status of American Indian and Alaska Native people. Pursuant to federal statute, TECs serve the 574 federally recognized Tribes (hereinafter, "Tribes") and their members across the United States, as well as American Indian and Alaska Native people in general. The COVID-19 pandemic has highlighted the need for timely, complete, and accurate public health data, particularly for American Indian and Alaska Native communities and others who may have been disproportionately impacted by COVID-19. This article reviews the history and importance of TECs and federal statutes governing TECs' ability to access and use protected health information for public health purposes. TECs and Tribes often encounter difficulty receiving public health data from state and federal agencies despite their designation as "public health authorities" under the Health Insurance Portability and Accountability Act and associated regulations. Limited access to this information hinders the statutory mission of TECs as well as Tribal monitoring of and response to public health threats such as SARS-CoV-2. Agency acknowledgment and compliance with current federal law regarding data sharing with TECs are essential to improve data access and the fragile public health of Tribal communities.

Understanding the Experiences of American Indian and Alaska Native Students Enrolled in Allopathic and Osteopathic Medical Degree Programs.

PURPOSE: Despite a growing population, American Indian and Alaska Native (AI/AN) students have seen no meaningful increase in representation in allopathic and osteopathic medical degree programs. While AI/AN medical students are more likely to practice in underserved areas, they face financial and sociocultural obstacles towards doing so. This underscores the need to understand the experiences of these trainees, and identify barriers and facilitators to the successful recruitment, retention, and advancement of AI/AN trainees. METHODS: A survey was administered to members of the Association of Native American Medical Students (ANAMS), an organization representing self-identified Native medical students. This survey elicited demographic information, opinions of institutional climate, and aspects of academic and social experiences during medical school. RESULTS: There were n = 39 complete responses. Over fifty percent of respondents (n = 21) identified as AI/AN alone and not in combination with another racial or ethnic group. Overall, respondents were: Generally, not satisfied with their school's engagement with Native communities and AI/AN health curricula. Likely to report barriers towards their timely advancement in training, namely being a first-generation or low income student, and feelings of imposter syndrome. Likely to report an interest to work in primary care fields and serve AI/AN communities in the future. CONCLUSIONS: This survey identified several barriers to successful AI/AN medical trainee advancement, highlighting opportunities for institutions to foster inclusion of AI/AN trainees and grow the number of Native physicians.

Infusing geriatrics in Indian Health Service general primary care clinics: Extending VA workforce development training.

As federal partners, the Veterans Health Administration (VA) and the Indian Health Service (IHS) agreed to share resources, such as education. The VA Geriatric Scholars Program, a workforce development program, provides one of its training programs on team-based primary care of elders to clinicians working in IHS and Tribal Health Programs. The practical impact of that training is described. A mixed methods approach was applied to the course's evaluation survey at five clinics in the Northwestern Plains, Southwest, Pacific Coast, and Alaska. Quantitative approaches assessed participants' self-reported intention to improve recognition and assessment of common geriatric syndromes. A qualitative approach applied to open-ended text responses revealed intensions to improve team-based care. Among the 51 respondents in our sample, we found significant improvements in self-reported ability to recognize previously unfamiliar potential risks to elders' health and safety, t(49) = 8.0233, p < .001, as well as increased comfort with conducting geriatric assessments and increased confidence in interprofessional team-based communication. Improvements to team-based care included enhanced clinical skills, organizational factors and the need to train additional employees. This evaluation demonstrates the value of sharing resources among federal partners and its value for participants in IHS and Tribal Health Programs.

American Indian and Alaskan Native Access to Obstetrics and Gynecology Subspecialists: Findings From a National Mystery Caller Study in the United States.

Background A significant disparity exists for American Indian and Alaska Native populations in accessing obstetric and gynecology (OBGYN) subspecialty care, as nearly 43% of individuals do not reside in areas where the Indian Health Service (IHS) provides care. Geographical separation from IHS facilities exacerbates healthcare disparities, particularly regarding access to specialized services. This study aims to create a map illustrating the average driving time from an IHS clinic to OBGYN subspecialists (e.g., gynecologic oncology, maternal-fetal medicine, family planning, urogynecology, pediatric and adolescent gynecology, and reproductive endocrinology and infertility [REI]) and determine the average wait time for appointments with these specialists. Study design A cross-sectional and mystery caller study was conducted using hospital-level data from the IHS and data on women from the 2010 United States Census provided by the US Census Bureau. All US OBGYN subspecialists were identified and mapped. The local distribution of clinics near IHS hospitals was determined, and the nearest OBGYN subspecialist was mapped to IHS hospitals providing women's care services. Thirty-seven OBGYN subspecialists closest to IHS hospitals were contacted to calculate the mean wait time for subspecialty care appointments. Results The median driving time to the closest gynecologic oncology, maternal-fetal medicine, family planning, urogynecology, pediatric and adolescent gynecology, and reproductive endocrinology and infertility OBGYN subspecialist was 214 minutes (interquartile range [IQR] 107-290). The longest drive to see a subspecialist for urogynecology services was over 240 minutes. From the 2010 US Census, we identified 583,574 American Indian and Alaska Native (AI/AN) pediatric, adolescent, and women within a 60-minute drive of an IHS hospital. The mean wait time for a new patient appointment was 13.6 business days (SD ± 2). Conclusions Geographical disparities significantly impact the ability of American Indian and Alaska Native populations to access OBGYN subspecialty care. There was no difference in wait times compared to the national average, though there were significantly longer drive times.

COVID-19 Vaccine Hesitancy in Middle-Aged and Older Adults in India: A Mixed-Methods Study.

INTRODUCTION: Vaccine hesitancy is a significant threat to public health efforts to stop the negative impacts of the COVID-19 pandemic. In India, it is critical to attain high vaccination rates to prevent overload in the healthcare system. Older adults play a central role in families' decision-making, but there is a lack of research on middle-aged and older adults' vaccine perceptions in India in general, and about their concerns about COVID-19 vaccinations. RESEARCH QUESTION: This study aimed to explore which factors affect COVID-19 vaccine hesitancy in middle-aged and older adults in India and what factors can reduce their vaccine hesitancy and increase its uptake. MATERIALS AND METHODS: A mixed-method sequential design was employed to conduct the study. Convenience sampling was used to recruit participants by sending an online invitation. For phase one of the study, a quantitative survey with 34 questions was distributed through WhatsApp. For phase two of the study, qualitative one-on-one interviews were conducted with those participants who completed the survey and agreed to participate in this next phase. RESULTS: In total, 65 individuals responded to the online survey and 10 participated in semi-structured interviews. The participants were residing in India and their age range was from 40 to 89 years. Analysis of the data identified that although the majority of participants supported the vaccine, the main reasons for vaccine hesitancy included uncertainty about the effectiveness of the vaccine, fear of side effects, unclear and insufficient information about the vaccines and altered risk perception. This study also showed that those who felt that the consequences of COVID-19 were mild were also more likely to be vaccine-hesitant. CONCLUSION: While the results of the study showed that most of the participants supported the COVID-19 vaccines, they expressed uncertainty regarding their effectiveness. The safety and effectiveness of the vaccines were found to be prime contributing factors to vaccine hesitancy in this sample. The findings from this pilot study can be used to develop a larger, more comprehensive study on vaccine hesitancy among middle-aged and older adults in India, which would provide more insights into strategies that can be employed to promote vaccinations.

Evaluating vaccination coverage and timeliness in American Indian/Alaska Native and non-Hispanic White children using state immunization information system data, 2015-2017.

Comprehensive estimates of vaccination coverage and timeliness of vaccine receipt among American Indian/Alaska Native (AI/AN) children in the United States are lacking. This study's objectives were to quantify vaccination coverage and timeliness, as well as the proportion of children with specific undervaccination patterns, among AI/AN and non-Hispanic White (NHW) children ages 0-24 months in Montana, a large and primarily rural U.S. state. Data from Montana's immunization information system (IIS) for children born 2015-2017 were used to calculate days undervaccinated for all doses of seven recommended vaccine series. After stratifying by race/ethnicity, up-to-date coverage at key milestone ages and the proportion of children demonstrating specific patterns of undervaccination were reported. Among n = 3,630 AI/AN children, only 23.1% received all recommended vaccine doses on-time (i.e., zero days undervaccinated), compared to 40.4% of n = 18,022 NHW children (chi-square p < 0.001). A greater proportion of AI/AN children were delayed at each milestone age, resulting in lower overall combined 7-vaccine series completion, by age 24 months (AI/AN: 56.6%, NHW: 64.3%, chi-square p < 0.001). As compared with NHW children, a higher proportion of AI/AN children had undervaccination patterns suggestive of structural barriers to accessing immunization services and delayed starts to vaccination. More than three out of four AI/AN children experienced delays in vaccination or were missing doses needed to complete recommended vaccine series. Interventions to ensure on-time initiation of vaccine series at age 2 months, as well initiatives to encourage completion of multi-dose vaccine series, are needed to reduce immunization disparities and increase vaccination coverage among AI/AN children in Montana.

Innovative and Integrated Contact Tracing: Indian Health Service, Arizona, December 2020-January 2021.

SARS-CoV-2 has exposed limitations of public health mitigation measures such as traditional case investigations and contact tracing. The Whiteriver Service Unit is a rural, acute care hospital on the Fort Apache Indian Reservation in Arizona with integrated health care delivery and public health services. During the first wave of COVID-19 cases in May-June 2020, we developed an innovative case investigation contact tracing approach that relied heavily on cross-trained personnel, in-person encounters, and baseline clinical evaluations. A second COVID-19 surge during December 13, 2020-January 31, 2021, caused incidence to peak at 413 cases per 100 000 community members. During that second surge, we investigated all 769 newly identified COVID-19 cases and notified 1911 (99.4%) of 1922 reported contacts. Median time interval from nasopharyngeal specimen collection to both case investigation and contact notification was 0 days (range, 0-5 days and 0-13 days, respectively). Our primary lesson was the importance of cross-trained personnel who integrated tasks along the testing-tracing continuum (eg, in-person interviews, prompt referral for additional testing and evaluation). These successive steps fed forward to identify new cases and their respective contacts. Our innovative community-based approach was both successful and efficient; our experience suggests that when adapted based on local needs, case investigation and contact tracing remain valuable and feasible public health tools, even in rural, resource-limited settings.

A Federal Indian Health Insurance Plan: Fulfilling a solemn obligation to American Indians and Alaska Natives in the United States.

The Indian Health Service (IHS) is but the latest effort to honor the constitutional and treaty commitment made to deliver health care to American Indians and Alaska Natives in the United States. The agency currently serves over 2.5 million American Indians and Alaska Natives through IHS-operated health facilities, as well provides funding support for contractual delivery of health services by Tribes to their constituents. Not unlike its predecessors, however, the IHS is struggling to fulfill its stated mission. Access to specialty care remains limited through the agency, particularly for Urban Indians, due to limited fiscal support of the Purchase-Referred Care Program. As a result of chronic underfunding stemming from Congressional inaction, the agency faces perennial understaffing and leadership turnover. In addition, the IHS is structurally unprepared to address the progressive urbanization of Alaska Natives and American Indians, more of whom now live in New York City than in North Dakota. Given these challenges, a renewed approach is warranted. In this essay, we review the history of the IHS, examine its current fiscal challenges, outline the ongoing demographic shift of AI/AN toward urban centers, and call for the creation of a Federal Indian Health Insurance Plan. Offered as a benefit to all American Indians and Alaska Natives without cost-sharing, the plan would be applicable both on and off tribal lands. Funded through mandatory appropriations, the plan would significantly increase fiscal support for AI/AN health programs and work to reduce health disparities affecting AI/ANs in the United States.

The Indian Health Service and American Indian/Alaska Native Health Outcomes.

The Indian Health Service (IHS) has made huge strides in narrowing health disparities between American Indian and Alaska Native (AI/AN) populations and other racial and ethnic groups. Yet, health disparities experienced by AI/AN people persist, with deep historical roots combined with present-day challenges. Here we review the history of the IHS from colonization to the present-day system, highlight persistent disparities in AI/AN health and health care, and discuss six key present-day challenges: inadequate funding, limited human resources, challenges associated with transitioning services from federal to Tribal control through contracting and compacting, evolving federal and state programs, the need for culturally sensitive services, and the promise and challenges of health technology.

Health insurance coverage among American Indians and Alaska Natives in the context of the Affordable Care Act.

Objectives: American Indians and Alaska Natives (AI/AN) have a unique healthcare system uniquely interwoven with the Affordable Care Act (ACA). The aim of this study is to document changes in health insurance among AI/AN adults before and after implementation of the ACA.Design: We used data from the American Community Survey from 2008 to 2016 to examine trends in health insurance. We compared to Non-Hispanic Whites and stratified AI/AN adults with and without Indian Health Service (IHS) coverage. We used multivariate regression to evaluate the probability of health insurance post-ACA and included time period and subgroup interaction terms.Results: Public and private health insurance coverage increased post-ACA by 3.17 and 1.24 percentage points, respectively, but the percent uninsured remained high (37.7% of those with IHS coverage and 19.2% of those without). AI/AN in Medicaid Expansion states had a significantly greater percentage point (pp) increase in public insurance (6.31 pp, 95% CI 5.04-7.59) than AI/AN in non-expansion states (p < 0.001). There was a greater increase in private coverage among AI/AN without IHS compared to AI/AN with IHS coverage (p = 0.002).Conclusions: Despite improvements in healthcare insurance coverage for AI/AN, substantial disparities remain. The improvements appeared to be largely driven by Medicaid Expansion. Without specific considerations for AI/AN, future healthcare reforms could intensify health injustices and inequities they face.

Experiences of Health Insurance among American Indian Elders and Their Health Care Providers.

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

Diabetes Prevention and Care Capacity at Urban Indian Health Organizations.

American Indian and Alaska Native (AI/AN) people suffer a disproportionate burden of diabetes and cardiovascular disease. Urban Indian Health Organizations (UIHOs) are an important source of diabetes services for urban AI/AN people. Two evidence-based interventions-diabetes prevention (DP) and healthy heart (HH)-have been implemented and evaluated primarily in rural, reservation settings. This work examines the capacity, challenges and strengths of UIHOs in implementing diabetes programs. Methods: We applied an original survey, supplemented with publicly-available data, to assess eight organizational capacity domains, strengths and challenges of UIHOs with respect to diabetes prevention and care. We summarized and compared (Fisher's and Kruskal-Wallis exact tests) items in each organizational capacity domain for DP and HH implementers vs. non-implementers and conducted a thematic analysis of strengths and challenges. Results: Of the 33 UIHOs providing services in 2017, individuals from 30 sites (91% of UIHOs) replied to the survey. Eight UIHOs (27%) had participated in either DP (n = 6) or HH (n = 2). Implementers reported having more staff than non-implementers (117.0 vs. 53.5; p = 0.02). Implementers had larger budgets, ~$10 million of total revenue compared to $2.5 million for non-implementers (p = 0.01). UIHO strengths included: physical infrastructure, dedicated leadership and staff, and community relationships. Areas to strengthen included: staff training and retention, ensuring sufficient and consistent funding, and data infrastructure. Conclusions: Strengthening UIHOs across organizational capacity domains will be important for implementing evidence-based diabetes interventions, increasing their uptake, and sustaining these interventions for AI/AN people living in urban areas of the U.S.

Efficacy of an mHealth Intervention (BRAVE) to Promote Mental Wellness for American Indian and Alaska Native Teenagers and Young Adults: Randomized Controlled Trial.

BACKGROUND: Culturally relevant interventions are needed to help American Indian and Alaska Native (AI/AN) teenagers and young adults navigate common risky situations involving family and friends, including drug and alcohol misuse, dating violence, and suicidality. Leveraging We R Native, a multimedia health resource for Native teenagers and young adults, staff of the Northwest Portland Area Indian Health Board designed the BRAVE intervention for Native youth. The program is delivered via SMS text messaging and includes role model videos, mental wellness strategies, links to culturally relevant resources, and social support from family and friends. OBJECTIVE: We aim to conduct a randomized controlled trial of the BRAVE intervention among AI/AN teenagers and young adults (aged 15-24 years) to assess its impact on their physical, mental, and spiritual health; their resilience and self-esteem; and their coping and help-seeking skills. METHODS: From October to December 2019, we recruited 2334 AI/AN teenagers and young adults nationwide via social media channels and SMS text messages and enrolled 1044 participants. AI/AN teenagers and young adults enrolled in the study received either BRAVE SMS text messages, designed to improve mental health, help-seeking skills, and cultural resilience, or 8 weeks of science, technology, engineering, and math (STEM) SMS text messages, designed to elevate and reaffirm Native voices in STEM and medicine and then received the BRAVE SMS text messages. The impacts of the BRAVE intervention were tested using linear mixed-effect models and linear regressions. RESULTS: A total of 833 AI/AN teenagers and young adults were included in the analysis. Individuals in the BRAVE and STEM arms showed significant positive trends over the course of the study for all outcomes, except cultural identity and help-seeking behavior. Mean scores were significantly different for health (P<.001), resilience (P<.001), negative coping (P=.03), positive coping (P<.001), self-efficacy (P=.02), and self-esteem (P<.001). Changes in help-seeking self-efficacy were significant in those exhibiting risky behaviors at baseline to exit (P=.01). Those who reported positive coping scores at baseline also reported better health on average; however, no difference was found in risky drug and alcohol use (P<.001). The number of participants who used SMS text messages to help themselves increased from 69.1% (427/618) at 3 months to 76% (381/501; P<.001) at 8 months. Similarly, the number of participants who used SMS text messages to help friends or family members increased from 22.4% (138/616) at 3 months to 54.6% (272/498) at 8 months. CONCLUSIONS: This is the first national randomized controlled trial of a mobile health intervention among AI/AN teenagers and young adults to test the efficacy of a mental wellness intervention in relation to STEM career messages. This study provides new insights for supporting the next generation of AI/AN changemakers. TRIAL REGISTRATION: ClinicalTrials.gov NCT04979481; https://clinicaltrials.gov/ct2/show/NCT04979481.

Narrative frames as choice over structure of American Indian sexual and reproductive health consequences of historical trauma.

Emerging evidence suggests that the historical trauma associated with settler colonialism affects the sexual and reproductive health (SRH) of American Indian (AI) communities today. This article examines how one AI community narratively frames the influence of historical trauma within the context of community-based participatory research (CBPR) and the implications of this framing for health behaviours, internalized oppression, SRH outcomes, and future CBPR interventions. We found that AIs framed the SRH consequences of historical trauma with renderings that favoured personal choice over structural explanations. Our findings suggest future interventions could: (1) include educational components on historical trauma and the continued role settler colonialism plays in structural violence against AI bodies and communities; and (2) recognize the role that the individualized logic of westernized/white culture may play in the erasure of traditional collectivist AI culture, internalized oppression, and SRH.