Rural Native Veterans' Perceptions of Care in the Context of Navigator Program Development.

INTRODUCTION: American Indian and Alaska Natives serve in the military at one of the highest rates of all racial and ethnic groups. For Veterans, the already significant healthcare disparities Natives experience are aggravated by barriers to accessing care, care navigation, and coordination of health care within the Veterans Health Administration (VHA) between the VHA and tribal health systems. To mitigate these barriers, the VHA is developing a patient navigation program designed specifically for rural Native Veterans. We describe formative work aimed at understanding and addressing barriers to VHA care from the perspective of rural Native Veterans and those who facilitate their care. METHODS: Thirty-four individuals participated in semi-structured interviews (22 Veterans, 6 family members, and 6 Veteran advocates) drawn from 9 tribal communities across the US. RESULTS: Participants described many barriers to using the VHA, including perceptions of care scarcity, long travel distances to the VHA, high travel costs, and bureaucratic barriers including poor customer service, scheduling issues, and long waits for appointments. Many Veterans preferred IHS/tribal health care over the VHA due to its proximity, simplicity, ease of use, and quality. CONCLUSION: Rural Native Veterans must see a clear benefit to using the VHA given the many obstacles to its use. Veteran recommendations for addressing barriers to VHA care within a navigation program include assistance enrolling in, scheduling, and navigating VHA systems; paperwork assistance; cost reimbursement; and care coordination with the IHS/tribal health care.

Cultural Unintelligibility and Marital Pressure: A Grounded Theory of Minority Stigma Against Women with Same-Sex Attraction in Mainland China.

Minority stigma against sexual minority women and its contributions to these women's health disparities have been widely investigated in Western countries. By contrast, little has been known about minority stigma against women with same-sex attraction (WSSA) in mainland China. This study aimed at exploring the nature, genesis, and pathways of minority stigma among this rarely studied minority group in terms of China's unique social and cultural organization of gender and sexuality. A grounded theory approach was applied to 28 participants of Chinese WSSA through in-depth telephone interviews to elicit their views and perspectives anchored in their daily experiences with gender hierarchy and normative heterosexuality. Findings of this study identified marital pressure and cultural unintelligibility as two principal components of minority stigma against Chinese WSSA. A conceptual framework was developed to illustrate how minority stigma relies on the mutually reinforcing loop of martial pressure and culturally unintelligible status of female same-sex attraction to oppress Chinese WSSA within and across intrapersonal, interpersonal, and structural levels. The parent-daughter relationship, laden with the Confucian value of filial piety, was highlighted as the major pathway of minority stigma to force Chinese women with same-sex attraction into heterosexual marriage and make female same-sex attraction culturally unintelligible. These findings lay a foundation for conceptualizing and measuring minority stigma of Chinese WSSA caused by the stigmatization of their same-sex attraction. Moreover, these findings would contribute greatly to understanding how cultural particularities critically affect the local process of stigmatization through which power relations and social control are practiced.

Gut Microbiome Diversity among Cheyenne and Arapaho Individuals from Western Oklahoma.

Existing studies characterizing gut microbiome variation in the United States suffer from population ascertainment biases, with individuals of American Indian ancestry being among the most underrepresented. Here, we describe the first gut microbiome diversity study of an American Indian community. We partnered with the Cheyenne and Arapaho (C&A), federally recognized American Indian tribes in Oklahoma, and compared gut microbiome diversity and metabolic function of C&A participants to individuals of non-native ancestry in Oklahoma (NNIs). While the C&A and NNI participants share microbiome features common to industrialized populations, the C&A participants had taxonomic profiles characterized by a reduced abundance of the anti-inflammatory bacterial genus Faecalibacterium, along with a fecal metabolite profile similar to dysbiotic states described for metabolic disorders. American Indians are known to be at elevated risk for metabolic disorders. While many aspects of this health disparity remain poorly understood, our results support the need to further study the microbiome as a contributing factor. As the field of microbiome research transitions to therapeutic interventions, it raises concerns that the continued exclusion and lack of participation of American Indian communities in these studies will further exacerbate health disparities. To increase momentum in fostering these much needed partnerships, it is essential that the scientific community actively engage in and recruit these vulnerable populations in basic research through a strategy that promotes mutual trust and understanding, as outlined in this study.

Assessment of elder mistreatment in two American Indian samples: psychometric characteristics of the HS-EAST and the Native Elder Life-Financial Exploitation and -Neglect measures.

Although elder mistreatment among ethnic minorities is increasingly gaining attention, our empirical knowledge of this phenomenon among American Indians remains quite limited, especially with respect to measurement. The Shielding American Indian Elders (SAIE) Project used a collaborative approach to explore culturally informed measurement of elder mistreatment in two American Indian elder samples (a Northern Plains reservation and a South Central metropolitan area). The project sought to investigate the performance characteristics of the commonly used Hwalek-Sengstock Elder Abuse Screening Test (HS-EAST), as well as to examine the psychometric properties of a new measure developed to capture culturally salient aspects of mistreatment in American Indian contexts--the Native Elder Life Scale (NELS). Using methods and samples comparable to those in the literature, the HS-EAST performed adequately in these Native samples. The NELS also shows promise for use with this population and assesses different aspects of elder mistreatment than does the HS-EAST.

Predictors of performance on the MMSE and the DRS-2 among American Indian elders.

Little is known about factors that predict older American Indians' performance on cognitive tests. This study examined 137 American Indian elders' performance on the MMSE and the Dementia Rating Scale-Second Edition (DRS-2). Multivariate regression identified younger age, more education, not receiving Supplemental Security Income, and frequent receipt of needed health care as predictors of better performance on the MMSE. Better performance on the DRS-2 was predicted by more education, boarding school attendance, not receiving Supplemental Security Income, and frequent receipt of needed health care. This study points to the importance of economic and educational factors on cognitive test performance among American Indian elders.

Suboptimal pharmacotherapy in a tribal nursing home.

OBJECTIVE: Suboptimal medication use among nursing home (NH) residents is common. NH residents tend to be older, suffer from multiple conditions, and take numerous medications, increasing their risk of serious complications. This article examines pharmacotherapy in a rural, tribally owned NH. DESIGN: Medical records were reviewed and case studies were conducted by a team composed of a medical anthropologist, psychiatrist, and geriatrician. SETTING: A rural, American Indian-owned NH in the US northern plains. PARTICIPANTS: 40 American Indian and 5 EuroAmerican NH residents. MEASUREMENTS: Minimum Data Set assessments, admission records, care plans, social histories, prescription lists, and behavioral consultation reports. RESULTS: Potential underuse affected almost 75% of residents; undertreatment of depressive and psychotic/agitated symptoms was especially common. Potential inappropriate use, especially of analgesics, psychotropics, and antihistamines, affected 30% of residents. A smaller, but still substantial, number of residents (21%) experienced potential overuse, much of which involved anticonvulsants, antibiotics, cardiovascular, and psychotropic agents. The prescription of 10 or more medications was significantly associated with potential drug interactions, as well as underuse, inappropriate medication use, and overuse. CONCLUSIONS: Psychotropic medications were the most potentially problematic medication category, and were strongly implicated in potential underuse, inappropriate use, and overuse. Fewer medications; the discontinuation of drugs known to be potentially problematic for NH residents; modification of psychotropic medication regimens; use of cognitive-enhancing medications where appropriate; implementation of an electronic medical record system; and greater use of nonpharmacological behavioral interventions may have substantially improved residents' treatment regimens.