Trusted Communicators: The Role of Navigation Support in Improving Health and Health Care Access for American Indian Elders.

Navigating health care and insurance systems presents significant challenges for American Indian (AI) Elders. Access to culturally congruent assistance with decision-making, scheduling, transportation, and communication can bridge the gap between AI Elders and health systems. This study uses qualitative interviews with professionals providing navigation services to American Indian Elders in a Southwestern state to understand the skills, experiences, and challenges involved in delivering this support. We conducted semi-structured interviews with 16 professionals providing navigation support to AI Elders between November 2018 and August 2020 and used a constant comparative approach to identify themes. Participants' descriptions of their work centered on the themes of (1) respect for Elders; (2) wide-ranging responsibilities; (3) acting as a trusted communicator; (4) developing trust; and (5) challenges to providing navigation support for AI Elders. Efforts to achieve health equity for AI Elders must include supporting individuals such as these within communities and advocating for a just health care system for American Indian people.

Implementation of LGBTQ+ affirming care policies in the Veterans Health Administration: preliminary findings on barriers and facilitators in the southern United States.

Background: In the United States Department of Veterans Affairs (VA), veterans who are lesbian, gay, bisexual, transgender, queer, and similar gender and sexual minoritized people (LGBTQ+) experience health disparities compared to cisgender, heterosexual veterans. VA's LGBTQ+ Health Program created two healthcare policies on providing LGBTQ+ affirming care (healthcare that is inclusive, validating, and understanding of the LGBTQ+ population). The current project examines providers' barriers and facilitators to providing LGBTQ+ affirming care and LGBTQ+ veterans' barriers and facilitators to receiving LGBTQ+ affirming care. Methods: Data collection and analysis were informed by the Consolidated Framework for Implementation Research, which was adapted to include three health equity domains. Data collection involved telephone interviews conducted with 11 VA providers and 12 LGBTQ+ veterans at one rural and one urban VA medical center, and one rural VA community clinic. Qualitative data were rapidly analyzed using template analysis, a data reduction technique. Results: Providers described limited education, limited time, lack of experience with the population, and a lack of awareness of resources as barriers. Providers discussed comfort with consulting trusted peers, interest in learning more about providing LGBTQ+ affirming care, and openness and acceptance of the LGBTQ+ community as facilitators. LGBTQ+ veterans described a lack of provider awareness of their needs, concerns related to safety and discrimination, and structural discrimination as barriers. LGBTQ+ veterans described positive relationships with providers, knowledge of their own healthcare needs, and ability to advocate for their healthcare needs as facilitators. Although VA's LGBTQ+ affirming care policies are in place, providers and veterans noted a lack of awareness regarding specific healthcare processes. Conclusion: Allowing more time and capacity for education and engaging LGBTQ+ veterans in determining how to improve their healthcare may be the path forward to increase adherence to LGBTQ+ affirming care policies. Engaging patients, especially those from marginalized backgrounds, in strategies focused on the uptake of policy may be a path to improve policy implementation. It is possible that creating truly collaborative structures in which patients, staff, providers, leadership, and policymakers can work together towards policy implementation may be a useful strategy. In turn, improved policy implementation would result in increased physical and mental health for LGBTQ+ veterans.

Causes and Consequences of Not Having a Personal Healthcare Provider Among American Indian Elders: A Mixed-Method Study.

Having a regular relationship with a healthcare provider contributes to better health outcomes and greater satisfaction with care for older adults. Although members of federally recognized American Indian tribes have a legal right to healthcare, American Indian Elders experience inequities in healthcare access that may compromise their ability to establish a relationship with a healthcare provider. This multi-year, community-driven, mixed-method study examines the potential causes and consequences of not having a personal healthcare provider among American Indian Elders. Quantitative surveys and qualitative interviews were conducted with 96 American Indian Elders (age 55 and over) in two states in the Southwestern United States. Quantitative and qualitative data were analyzed separately and then triangulated to identify convergences and divergences in data. Findings confirmed that having a consistent healthcare provider correlated significantly with self-rated measures of health, confidence in getting needed care, access to overall healthcare, and satisfaction with care. Lack of a regular healthcare provider was related to interconnected experiences of self-reliance, bureaucratic and contextual barriers to care, and sentiments of fear and mistrust based in previous interactions with medical care. Increasing health equity for American Indian Elders will thus require tailored outreach and system change efforts to increase continuity of care and provider longevity within health systems and build Elders' trust and confidence in healthcare providers.

The Community as the Unit of Healing: Conceptualizing Social Determinants of Health and Well-Being for Older American Indian Adults.

BACKGROUND AND OBJECTIVES: Multiple racial and social inequities shape health and access to health care for American Indian Elders, who have a lower life expectancy than all other aging populations in the United States. This qualitative study examines how upstream social determinants of health influence Elders' ability to access and use health care. RESEARCH DESIGN AND METHODS: Between June 2016 and March 2017, we conducted individual, semistructured interviews with 96 American Indian Elders, aged 55 and older, and 47 professionals involved in planning or delivering care to Elders in 2 states in the U.S. Southwest. Transcripts were analyzed iteratively using grounded theory approaches, including open and focused coding. A group of American Indian Elders and allies called the Seasons of Care Community Action Board guided interpretation and prioritization of findings. RESULTS: Participants described multiple barriers that hindered Elders' ability to access health care services and providers, which were largely tied to funding shortages and bureaucratic complexities associated with health care and insurance systems. Where available, community resources bridged service gaps and helped Elders navigate systems. DISCUSSION AND IMPLICATIONS: Longstanding structural inequities for American Indians manifest in barriers to health equity, many of which are situated at the community level. These are compounded by additional disparities affecting older adults, rural residents, and marginalized citizens in general. Findings underscore the importance of health and policy initiatives for American Indian Elders that emphasize the community as the focus of intervention.

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.

Power and resistance in schools: Implementing institutional change to promote health equity for sexual and gender minority youth.

Introduction: Schools in the United States are hierarchical institutions that actively (re)produce the power relations of the wider social world, including those associated with heteronormativity. Structural stigma, informed by heteronormativity and perpetuated through schools, contributes to the production of academic and health disparities among youth who are lesbian, gay, bisexual, transgender, queer, or of other gender and sexual identities (LGBTQ+). We draw upon 5 years of qualitative data from a cluster randomized controlled trial conducted in New Mexico that used implementation science frameworks to promote the uptake and sustainment of evidence-informed practices (EIPs) to examine how power operates to hinder or promote the ability of school staff to change school environments, disrupt structural stigma, and increase safety and support for LGBTQ+ youth. Methods: Data sources included annual individual and small group qualitative interviews with school professionals (e.g., administrators, school nurses, teachers, and other staff), several of whom took part in Implementation Resource Teams (IRTs) charged with applying the EIPs. Other data sources included bi-weekly periodic reflections with implementation coaches and technical assistance experts. Data were recorded, transcribed, and analyzed using deductive and inductive coding techniques. Results: The IRTs experienced variable success in implementing EIPs. Their efforts were influenced by: (1) constraining school characteristics, including staff turnover and resource scarcity; (2) community-based opposition to change and concerns about community backlash; (3) the presence or absence of supportive school leadership; and (4) variations in school, district, and state policies affecting LGBTQ+ students and attitudes about their importance. Findings illustrate how diverse power structures operated in and across outer and inner contexts to bound, shift, amplify, and otherwise shape how new practices were received and implemented. Conclusion: Findings indicate that the efforts of IRTs were often a form of resistant power that operated within and against school hierarchies to leverage epistemic, discursive, and material power toward implementation. To improve health equity, implementation scientists must attend to the multiple real and perceived power structures that shape implementation environments and influence organizational readiness and individual motivation. Implementers must also work to leverage resistant power to counter the institutional structures and social norms that perpetuate inequities, like heteronormativity and structural stigma.

Assessing readiness factors for implementation of LGBTQ+ affirmative primary care initiatives: Practice implications from a mixed-method study.

Introduction: Access and utilization barriers in primary care clinics contribute to health disparities that disproportionately affect lesbian, gay, bisexual, transgender, and queer (LGBTQ+) people. Implementing inclusive practice guidelines in these settings may decrease disparities. The purpose of this exploratory/developmental study is to identify key issues affecting the readiness of primary care clinics to implement such guidelines. Methods: Using a concurrent mixed-method research design, we conducted surveys, interviews, and focus groups with 36 primary care personnel in clinics in New Mexico, USA, to examine readiness to implement LGBTQ+ inclusive guidelines, analyzing factors affecting motivation, general organizational capacity, and innovation-specific capacity. We supplemented these data by documenting LGBTQ+ inclusive policies and practices at each clinic. We undertook descriptive analyses and between-subscale comparisons controlling for within-rater agreement of the survey data and iterative coding and thematic analysis of the qualitative data. Results: Quantitatively, participants reported significantly more openness toward adopting guidelines and attitudinal awareness for developing LGBTQ+ clinical skills than clinical preparedness, basic knowledge, and resources to facilitate implementation. Six themes derived from the qualitative findings corroborate and expand on these results: (1) treating all patients the same; (2) addressing diversity in and across LGBTQ+ populations; (3) clinic climates; (4) patient access concerns; (5) insufficient implementation support; and (6) leadership considerations. Conclusion: This study demonstrates that personnel in primary care clinics support initiatives to enhance service environments, policies, and practices for LGBTQ+ patients. However, drawing on Iris Young's theory of structural injustice, we found that neutralizing discourses that construct all patients as the same and time/resource constraints may diminish motivation and capacity in busy, understaffed clinics serving a diverse clientele and reinforce inequities in primary care for LGBTQ+ people. Efforts are needed to build general and innovation-specific capacities for LGBTQ+ initiatives. Such efforts should leverage implementation teams, organizational assessments, education, leadership support, community engagement, and top-down incentives.

Using Concept Mapping to Understand Gender- and Age-Specific Factors Influencing Health Care Access among American Indian Elders.

Inequities in access to health care create barriers to physical and mental health treatment for the rapidly aging American Indian population in the United States. This study uses concept mapping-a participatory, mixed-methods approach to understanding complex phenomena-to examine the perceived impacts of multilevel factors influencing Elders' ability to access and use health care and how these perceptions vary according to gender and age, with the aim of identifying tailored strategies to address inequities. Using data from a purposive sample of American Indian Elders (n = 65) in two states, we compared ratings of thematic clusters and individual factors perceived to impact Elder health care across four participant subgroups: women aged 55-64, women aged 65+, men aged 55-64, and men aged 65+. Provider Issues and Relationships and Tribal/National Policy were themes perceived to have a particularly high impact on Elder health. Key variations between subgroups regarding individual health care access factors reflected unique interpersonal and accessibility challenges among older women, problems stemming from lack of familiarity with health care among younger Elders and men, and challenges navigating complex bureaucracies and tribal decision-making processes among older Elders. Findings underscore the need to address multilevel gender- and age-specific factors contributing to health disparities for Elders.

Intimate Partner Violence and Structural Violence in the Lives of Incarcerated Women: A Mixed-Method Study in Rural New Mexico.

Intimate partner violence (IPV) is a common feature in the lives of incarcerated women returning to rural communities, enhancing their risk of mental ill-health, substance use, and recidivism. Women's experiences of IPV intersect with challenges across multiple social-ecological levels, including risky or criminalizing interpersonal relationships, geographic isolation, and persistent gender, racial, and economic inequities. We conducted quantitative surveys and qualitative interviews with 99 incarcerated women in New Mexico who were scheduled to return to micropolitan or non-core areas within 6 months. Quantitative and qualitative data were analyzed separately and then triangulated to identify convergences and divergences in data. The findings underscore how individual and interpersonal experiences of IPV, substance use, and psychological distress intersect with broad social inequities, such as poverty, lack of supportive resources, and reluctance to seek help due to experiences of discrimination. These results point to the need for a more proactive response to the mutually constitutive cycle of IPV, mental distress, incarceration, and structures of violence to improve reentry for women returning to rural communities. Policy and treatment must prioritize socioeconomic marginalization and expand community resources with attention to the needs of rural women of color.

Macro- and meso-level contextual influences on health care inequities among American Indian elders.

BACKGROUND: American Indian elders, aged 55 years and older, represent a neglected segment of the United States (U.S.) health care system. This group is more likely to be uninsured and to suffer from greater morbidities, poorer health outcomes and quality of life, and lower life expectancies compared to all other aging populations in the country. Despite the U.S. government's federal trust responsibility to meet American Indians' health-related needs through the Indian Health Service (IHS), elders are negatively affected by provider shortages, limited availability of health care services, and gaps in insurance. This qualitative study examines the perspectives of professional stakeholders involved in planning, delivery of, and advocating for services for this population to identify and analyze macro- and meso-level factors affecting access to and use of health care and insurance among American Indian elders at the micro level. METHODS: Between June 2016 and March 2017, we undertook in-depth qualitative interviews with 47 professional stakeholders in two states in the Southwest U.S., including health care providers, outreach workers, public-sector administrators, and tribal leaders. The interviews focused on perceptions of both policy- and practice-related factors that bear upon health care inequities impacting elders. We analyzed iteratively the interview transcripts, using both open and focused coding techniques, followed by a critical review of the findings by a Community Action Board comprising American Indian elders. RESULTS: Findings illuminated complex and multilevel contextual influences on health care inequities for elders, centering on (1) gaps in elder-oriented services; (2) benefits and limits of the Affordable Care Act (ACA); (2) invisibility of elders in national, state, and tribal policymaking; and (4) perceived threats to the IHS system and the federal trust responsibility. CONCLUSIONS: Findings point to recommendations to improve the prevention and treatment of illness among American Indian elders by meeting their unique health care and insurance needs. Policies and practices must target meso and macro levels of contextual influence. Although Medicaid expansion under the ACA enables providers of essential services to elders, including the IHS, to enhance care through increased reimbursements, future policy efforts must improve upon this funding situation and fulfill the federal trust responsibility.

A randomized control trial to test a peer support group approach for reducing social isolation and depression among female Mexican immigrants.

BACKGROUND: Female Mexican Immigrants (FMIs) experience high rates of depression compared with other populations. For this population, depression is often exacerbated by social isolation associated with the experience of immigration. Aim 1. To measure whether a culturally situated peer group intervention will reduce depression and stress associated with the experience of immigration. Aim 2. To test whether an intervention using a "women's funds of knowledge" approach results in improved resilience, knowledge and empowerment. Aim 3. To investigate whether a culturally situated peer group intervention using a women's funds of knowledge approach can give participants a sense and experience of social and physical connection ("emplacement") that is lost in the process of immigration. METHODS: This mixed-methods study will implement "Tertulias" ("conversational gatherings" in Spanish), a peer support group intervention designed to improve health outcomes for FMI participants in Albuquerque, New Mexico. We will document results of the intervention on our primary hypotheses of a decrease in depression, and increases in resilience and social support, as well as on our secondary hypotheses of decreased stress (including testing of hair cortisol as a biomarker for chronic stress), and an increase in social connectedness and positive assessment of knowledge and empowerment. DISCUSSION: This project will address mental health disparities in an underserved population that experiences high rates of social isolation. Successful completion of this project will demonstrate that health challenges that may appear too complex and too hard to address can be using a multi-level, holistic approach. Our use of hair samples to test for the 3-month average levels of systemic cortisol will contribute to the literature on an emerging biomarker for analyzing chronic stress. TRIAL REGISTRATION: This study was registered with ClinicalTrials.gov on 2/3/20, Identifier # NCT04254198 .

Getting to Know: American Indian Elder Health Seeking in an Under-funded Healthcare System.

American Indian (AI) Elders are the heart of the community. Existing research explores links between specific health behaviors and social determinants of health, but there is little theory explaining patient behaviors in the context of the Indian Health Service (IHS) system of care. We drew from a multiyear mixed-methods participatory study of Elder healthcare experiences to identify the systemic, interpersonal, and historic factors in the IHS that impact their health-seeking behaviors. We conducted an interpretive grounded theory analysis guided by Indigenous methodologies to analyze interviews with 96 AI Elders from two Southwestern states. Our resulting theory, Getting to Know, explains how Elders knew, owned, accessed, and were denied information and resources in their efforts to receive care. Findings highlight how Elders' health-seeking behaviors reflect longstanding inequities, the many ways Elder knowledge was incongruent with Western knowledge embedded in the IHS system, and how this conflict contributed to Elder discomfort in clinical settings. Future work will test the applicability of Getting to Know in other AI communities and design culturally safe care to meet Elder needs. By applying an Indigenous-centered analysis to the voices of Elders, we identified key influences on health outcomes not previously observed in the literature. By illuminating these influences, we show how culturally safe care can be better formulated to meet the needs of Elders, ultimately improving health for AI communities.

Amplification of school-based strategies resulting from the application of the dynamic adaptation process to reduce sexual and gender minority youth suicide.

BACKGROUND: Evidence-informed practices (EIPs) are imperative to increase school safety for lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) students and their peers. Recently, the Expert Recommendations for Implementing Change (ERIC), a taxonomy of discrete implementation strategies used in health care settings, was adapted for schools. The School Implementation Strategies, Translating the ERIC Resources (SISTER) resulted in 75 discrete implementation strategies. In this article, we examine which SISTER strategies were used to implement six EIPs to reduce suicidality among LGBTQ high school students. We applied the dynamic adaptation process (DAP), a phased, data-driven implementation planning process, that accounts for adaptation while encouraging fidelity to the core elements of EIPs. METHODS: Qualitative data derived from 36 semi-structured interviews and 16 focus groups conducted with school professionals during the first of a 3-year effort to implement EIPs in 19 high schools. We undertook iterative comparative analysis of these data, mapping codes to the relevant domains in the SISTER. We then synthesized the findings by creating a descriptive matrix of the SISTER implementation strategies employed by schools. RESULTS: We found that 20 SISTER strategies were encouraged under the DAP, nine of which were amplified by school personnel. Nine additional SISTER strategies not specifically built into the DAP were implemented independently by school personnel, given the freedom the DAP provided, resulting in a total of 29 SISTER strategies. CONCLUSION: This study offers insight into how schools select and elaborate implementation strategies. The DAP fosters freedom to expand beyond study-supported strategies. Qualitative data illuminate motives for strategy diversification, such as improving EIP fit. Qualitative methods allow for an in-depth illustration of the strategies that school personnel enacted in their efforts to implement the EIPs. We discuss the utility of the DAP in supporting EIP implementation to reduce disparities for LGBTQ students. PLAIN LANGUAGE ABSTRACT: Implementation science is, in part, concerned with implementation strategies, which are actions made to bridge implementation gaps between evidence-informed practices and the contexts in which practices are to be used. Implementation experts compiled a list of strategies for promoting the use of new practices in school settings. The authors of this article examine which implementation strategies in this list were promoted by the research team and which were employed independently by school personnel. Our results illustrate how school personnel applied strategies based on the conditions and needs of their individual schools. These results will contribute to knowledge about implementation strategies and improve readiness by building in strategies implementation teams will use. The authors conducted interviews and focus groups with school personnel involved in implementing six evidence-informed practices for reducing suicidality and other negative outcomes for lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) high school students. Findings are from the end of the first year of implementation and provide a glimpse into how and why certain implementation strategies were employed by school personnel to facilitate adoption of the practices. Findings describe how they applied these strategies in communities where LGBTQ people were marginalized and where anti-LGBTQ stigma influenced policies and resulted in barriers to implementation. This article contributes to efforts to identify and tailor implementation strategies that can encourage the use of evidence-informed practices to improve the well-being of LGBTQ youth and other health disparity populations.

Health Care Access and Utilization for American Indian Elders: A Concept-Mapping Study.

OBJECTIVES: Inequities in access to and utilization of health care greatly influence the health and quality of life of American Indian elders (AIEs). This study explores the importance and perceived prevalence of factors affecting health care use within this population and assesses the changeability of these factors to produce a list of action items that are timely and relevant to improving health care access and utilization. METHOD: Concept mapping was conducted with AIEs (n = 65) and professional stakeholders (n = 50), including tribal leaders, administrators of public-sector health systems, outreach workers, and health care providers. Data were analyzed using multidimensional scaling and cluster analyses. RESULTS: The final concept-map model comprised nine thematic clusters related to factors affecting elder health care: Difficulties Obtaining and Using Insurance; Insecurity from Lack of Knowledge; Limited Availability of Services; Scheduling Challenges; Provider Issues and Relationships; Family and Emotional Challenges; Health-Related Self-Efficacy and Knowledge; Accessibility and Transportation Barriers; and Tribal/National Policy. DISCUSSION: Findings suggest that improvements in access to and utilization of health care among AIEs will require actions across multiple domains, including health system navigation services, workforce improvements, and tribal, state, and federal policy. A multilevel socioecological approach is necessary to organize and undertake these actions.

Producing insecurity: Healthcare access, health insurance, and wellbeing among American Indian elders.

Although health care is a treaty-guaranteed right for members of federally recognized tribes, decades of research describe persistent disparities in health and access to health services for American Indians. Despite gains in insurance enrollment after the passage of the 2010 Affordable Care Act, underfunding of the Indian Health Service and national debate over the new health law contributes to insecurity, especially among the majority of American Indians aged 55 and older who rely on public insurance. We consider the production of insecurity surrounding health care for American Indian elders, analyzing its pragmatic and affective consequences. Between June 2016 and March 2017, we conducted 96 quantitative surveys and in-depth qualitive interviews with American Indian elders aged 55 and older in two states in the U.S. Southwest. Interviews were recorded, professionally transcribed, and analyzed iteratively using open and focused coding. We found that elders consistently shared discourses of doubt, fear, and uncertainty that centered on: 1) interactions with healthcare providers and facilities, especially the IHS; 2) calculations regarding health insurance and the potential costs of healthcare services; and 3) dynamics at the national level around health policy, particularly for American Indians. We argue that persistent perceptions of healthcare insecurity present a major barrier to wellbeing that remains unaddressed by existing health policy interventions for this population, which focus predominately on individual-level knowledge and behavior.

Applying a Structural-Competency Framework to the Implementation of Strategies to Reduce Disparities for Sexual and Gender Minority Youth.

BACKGROUND: Sexual and gender minority youth (SGMY) are at high risk for adverse health outcomes. Safer schools decrease this risk. The US Centers for Disease Control and Prevention has identified 6 practices that can make schools safer for SGMY, yet few US schools implement them all. We apply a structural competency framework to elucidate factors contributing to this implementation gap. METHODS: We conducted 75 interviews and 32 focus groups with school professionals in 18 New Mexico high schools to assess factors impacting implementation of the practices over 2 years. We analyzed data using iterative coding, thematic identification techniques, and the sensitizing concept of structural competency. RESULTS: Themes included: rendering an invisible population visible; critical thinking about LGBTQ inequalities; building school personnel capacity; intersecting cultural, religious, and political conflicts; and tackling community-based sources of stigma and discrimination. CONCLUSIONS: Underlying cultural and structural forces render SGMY invisible and constrain what schools can accomplish. Professional development encouraging critical thinking about structural inequities is foundational, but efforts to close the implementation gap must attend to structural forces producing disparities for SGMY. Structural competency can strengthen the ability of the Whole School, Whole Community, and Whole Child model's cross-sector coordination of policy and process to meet the needs of every student.

"Creative Financing": Funding Evidence-Based Interventions in Human Service Systems.

Implementation and sustainment of evidence-based interventions (EBIs) is influenced by outer (e.g., broader environments in which organizations operate) and inner (e.g., organizations, their administrators, and staff) contexts. One important outer-context element that shapes the inner context is funding, which is complex and unpredictable. There is a dearth of knowledge on how funding arrangements affect sustainment of EBIs in human service systems and the organizations delivering them, including child welfare and behavioral health agencies. This study uses qualitative interview and focus group data with stakeholders at the system, organizational, and provider levels from 11 human service systems in two states to examine how stakeholders strategically negotiate diverse and shifting funding arrangements over time. Study findings indicate that, while diverse funding streams may contribute to flexibility of organizations and possible transformations in the human service delivery environment, a dedicated funding source for EBIs is crucial to their successful implementation and sustainment.

"Improving Native American elder access to and use of health care through effective health system navigation".

BACKGROUND: Public insurance reforms of the past two decades have failed to substantively address the healthcare needs of American Indians in general, let alone the particular needs of American Indian elders, ages 55 years and older. Historically, this population is more likely to be uninsured and to suffer from greater morbidities, poorer health outcomes and quality of life, and lower life expectancies compared to all other United States aging populations, representing a neglected group within the healthcare system. Despite the pervasive belief that the Indian Health Service will address all their health-related needs, American Indian elders are negatively affected by gaps in insurance and lack of access to health care. While the 2010 Patient Protection and Affordable Care Act included provisions to ameliorate disparities for American Indians, its future is uncertain. In this context, American Indian elders with variable health literacy must navigate a complex and unstable healthcare system, regardless of where they seek care. METHODS: This community-driven study features a mixed-method, participatory design to examine help-seeking behavior and healthcare experiences of American Indian elders in New Mexico, in order to develop and evaluate a tailored intervention to enhance knowledge of, access to, and use of insurance and available services to reduce healthcare disparities. This study includes qualitative and quantitative interviews combined with concept mapping and focus groups with American Indian elders and other key stakeholders. DISCUSSION: The information gathered will generate new practical knowledge, grounded in actual perspectives of American Indian elders and other relevant stakeholders, to improve healthcare practices and policies for a population that has been largely excluded from national and state discussions of healthcare reform. Study data will inform development and evaluation of culturally tailored programming to enhance understanding and facilitate negotiation of the changing landscape of health care by American Indian elders. This work will fill a gap in research on public insurance initiatives, which do not typically focus on this population, and will offer a replicable model for enhancing the effects of such initiatives on other underserved groups affected by healthcare inequities. TRIAL REGISTRATION: This protocol does not include the collection of health outcome data. Clinicaltrials.gov, NCT03550404 . Registered June 6, 2018.

A Mixed-Method Assessment of a Pilot Peer Advocate Intervention for Rural Gender and Sexual Minorities.

Mental health disparities affect lesbian, gay, bisexual, transgender, and queer (LGBTQ) people in rural America. There are few empirically-based mental health interventions for this population. This exploratory study uses a mixed-method approach to assess implementation issues related to the feasibility, acceptability, appropriateness, and preliminary impacts of a novel peer-based intervention designed to enhance support and treatment engagement among rural LGBTQ people with mental distress and/or addiction issues. Quantitative and qualitative results illuminate intervention strengths and areas for improvement. Strengths centered on enhancing social support, advocacy behaviors, and engagement in treatment. Implementation challenges and recommendations to advance the intervention model are discussed.

Coaching mental health peer advocates for rural LGBTQ people.

Lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) people are affected by mental health disparities, especially in rural communities. We trained peer advocates in rural areas in the fundamentals of mental health, outreach, education, and support for this population. The peer advocates were coached by licensed mental health professionals. We evaluated this process through iterative qualitative analysis of semi-structured interviews and written logs from coaches and advocates. The six major themes comprising the results centered on (1) coaching support, (2) peer advocate skills and preparation, (3) working with help seekers, (4) negotiating diversity, (5) logistical challenges in rural contexts, and (6) systemic challenges. We concluded that peer advocacy for LGBTQ people with mental distress offers an affirmative, community-based strategy to assist the underserved. To be successful, however, peer advocates will likely require ongoing training, coaching, and infrastructural support to negotiate contextual factors that can influence provision of community resources and support to LGBTQ people within rural communities.