Black Alaskans Health Needs Assessment during COVID-19 Pandemic: Implications for Social Work.

At the peak of the COVID-19 pandemic it became clear that Black people were experiencing more severe symptoms and had higher rates of mortality from COVID-19 than White people. However, data on racial differences in death and hospitalization rates in Alaska were less clear. To address this, the Alaska Black Caucus initiated the first Black Alaskans health needs assessment to understand the health status, needs, and resources of the Black community of Alaska. This article reports on the design, implementation, and descriptive results from the survey portion of the first community health needs assessment of Black Alaskans. The findings indicate that a majority of Black Alaskans report being moderately healthy, having access to health insurance, owning their homes, and having a favorable view of their neighborhood. However, too many are unable to work due to poor physical or mental health challenges and are diagnosed with one or more chronic health diseases. In addition, Black Alaskans experience high rates of substance abuse, have untreated mental health conditions, consume tobacco products at a high rate, and are not screening for some cancers. The article will conclude by presenting additional strategies for improving healthcare access and responsiveness for Black Alaskans.

Economic incentives surrounding fertility: Evidence from Alaska's permanent fund dividend.

The Alaska Permanent Fund Dividend provided an incentive that increased fertility. This paper estimates the impact of the dividend transfer on fertility rates in Alaska compared to other states using the synthetic control methodology. For the period from 1982 to 1988, fertility on average increased annually in Alaska by 11.3 births per 1000 women aged 15-44-a 13.1 percent increase over the counterfactual. This was driven by women over 20. Fertility increased for women aged 20-24 by 12.4 percent, those aged 25-34 by 14.3 percent, and those aged 35-44 by 16.9 percent. The paper also finds support that narrowing the gap between births, increase in total fertility rate, and no change in abortion are potential channels for the observed increase in fertility. No change in the fertility for the adolescents combined with no change in abortion suggests that the increase in fertility in Alaska was planned.

Application of COVIDTracer to Inform Public Health Workforce Planning in Alaska During the COVID-19 Pandemic.

The COVID-19 pandemic has caused social and economic disruption worldwide and spurred numerous mitigation strategies, including state investments in training a large contact tracing and case investigation workforce. A team at the University of Alaska Anchorage evaluated implementation of the COVID-19 contact tracing and case investigation program of the State of Alaska Department of Health and Social Services, Division of Public Health, Section of Public Health Nursing. As part of that evaluation, the team used COVIDTracer, a spreadsheet modeling tool. COVIDTracer generated projections of COVID-19 case counts that informed estimates of workforce needs and case prioritization strategies. Case count projections approximated the reported epidemiologic curve with a median 7% difference in the first month. The accuracy of case count predictions declined after 1 month with a median difference of 80% in the second month. COVIDTracer inputs included previous case counts, the average length of time for telephone calls to cases and outreach to identified contacts, and the average number of contacts per case. As each variable increased, so too did estimated workforce needs. Decreasing the average time from exposure to outreach from 10 to 5 days reduced case counts estimated by COVIDTracer by approximately 93% during a 5-month period. COVIDTracer estimates informed Alaska's workforce planning and decisions about prioritizing case investigation during the pandemic. Lessons learned included the importance of being able to rapidly scale up and scale down workforce to adjust to a dynamic crisis and the limitations of prediction modeling (eg, that COVIDTracer was accurate for only about 1 month into the future). These findings may be useful for future pandemic preparedness planning and other public health emergency response activities.

Traumatic injuries among Alaska's young workers: Linking cases from four data systems.

BACKGROUND: Young workers (aged 15-24 years) experience higher rates of job-related injury compared with workers aged 25-44 years in the United States. Young workers may have limited or no prior work experience or safety training, which can contribute to their injury risk. In 2018, Alaska had the second highest work-related fatality rate and 14th highest non-fatal injury rate in the United States. This study aimed to characterize nonfatal and fatal occupational injuries among young workers in Alaska. METHODS: To describe injury patterns among Alaska young workers from 2014-2018, we used data from four datasets: Alaska Workers' Compensation, Alaska Occupational Injury Surveillance System, Alaska Trauma Registry, and Alaska Fishermen's Fund. The datasets were merged two at a time and filtered by the worker characteristics (e.g., age and sex) and incident characteristics (e.g., date of injury). Duplicates were then manually identified between the datasets using the variables above. The injury narrative and Occupational Injury and Illness Classification System codes were used last to verify true duplicates. Descriptive analyses were performed after the duplicates were merged. RESULTS: During the 5-year study period 2014-2018, young workers experienced 20 fatal and 12,886 nonfatal injuries. Residents of Alaska comprised 85% of nonfatal and 70% of fatal injuries. The top three major occupation groups with the highest number of injuries were production (1,391, 14%), food preparation (1,225, 12%), and transportation/material moving (1,166, 11%). The most common events leading to injuries were struck by object or equipment (2,027, 21%), overexertion involving outside sources (1,385, 14%), and struck against object or equipment (905, 9%). The most common nature of injuries were sprains/strains/tears (3,024, 29%), cuts/lacerations (1,955, 19%), and bruises/contusions (1,592, 15%). CONCLUSION: Although progress has been made in reducing worker injuries, Alaskan young workers still experience injuries and fatalities frequently. Based on findings, there is a clear need for employers, researchers, public health professionals, parents, and young workers to prioritize young worker safety through an integrated approach, from education and training to adequate workplace supervision and support.

The maternal health of American Indian and Alaska Native people: A scoping review.

Indigenous people in the United States experience disadvantage in multiple domains of health. Yet, their maternal health receives limited research attention. With a focus on empirical research findings, we conduct a scoping review to address two questions: 1) what does the literature tell us about the patterns and prevalence of maternal mortality and morbidity of American Indian and Alaska Native (AI/AN) people? and 2) how do existing studies explain these patterns? A search of CINAHL, Embase and Medline yielded 4757 English-language articles, with 66 eligible for close review. Of these, few focused specifically on AI/AN people's maternal health. AI/AN people experience higher levels of maternal mortality and morbidity than non-Hispanic White people, with estimates that vary substantially across samples and geography. Explanations for the maternal health of AI/AN people focused on individual factors such as poverty, cultural beliefs, and access to healthcare (e.g. lack of insurance). Studies rarely addressed the varied historical and structural contexts of AI/AN tribal nations, such as harms associated with colonization and economic marginalization. Research for and by Indigenous communities and nations is needed to redress the effective erasure of AI/AN people's maternal health experiences and to advance solutions that will promote their health and well-being.

Needs assessment of cancer survivors in Alaska.

PURPOSE: Little is known about cancer survivors' needs in Alaska. To address this knowledge gap, the Alaska Cancer Partnership conducted a needs assessment survey; our objectives were to identify unmet needs of Alaska's cancer survivors; identify survivor sub-populations that might benefit from targeted interventions or programming; and develop recommendations for public health and community organizations and healthcare providers for addressing cancer survivors' unmet needs. METHODS: Cancer survivors were identified using data from the Alaska Cancer Registry. A random sample of 2,600 individuals was selected to receive the survey, which assessed unmet needs across the following domains: information needs and medical care issues; quality of life; emotional and relationship issues related to cancer diagnoses; and support services. We calculated descriptive statistics for survey responses and assessed demographic predictors of unmet needs using Poisson regression. RESULTS: We received 335 survey responses, for a response of 13.7%. Only 29.9% of cancer survivors expressed that all their needs were met. The most highly ranked unmet needs were as follows: help to reduce stress in life; to know doctors were coordinating care; and managing concerns about cancer coming back. After adjustment, men, adults younger than 65 at diagnosis, Alaska Native people, survivors still receiving or who had recently received care, and people who had to travel 50+ miles for most of their care had significantly greater unmet needs than their comparison groups. CONCLUSION: This assessment provided some of the first information regarding the needs of Alaska's cancer survivors. These results will be used by Alaska Cancer Partnership members across the state to inform healthcare delivery, programs, and public health messaging to support survivors.

Health-related economic benefits of universal access to piped water in Arctic communities: Estimates for the Yukon-Kuskokwim Delta region of Alaska.

This paper presents estimates of the potential health-related economic benefits of providing universal access to in-home water and sanitation services to households in rural Alaska. In particular, we use data on disease incidence rates, health care costs, and local estimates of the impact of piped water on disease reduction to estimate the potential health-related economic benefits of providing universal access to piped water in the Yukon Kuskokwim (Y.K.) Delta region of Alaska. We include estimates of avoided treatment and diagnosis costs as well as private benefits associated with reduced morbidity and mortality associated with improved access to in-home piped water. To our knowledge, these are the first estimates of the economic benefits of improved access to water and sanitation in rural Alaska and the Arctic. Our analysis suggests increased access to in-home piped water in the region may yield substantial reductions in direct medical expenses incurred by public agencies and families, as well as reductions in time and travel costs associated with improved health outcomes. These benefits, along with the array of health and non-health-related benefits not included in our analysis, may provide new impetus to expanding access to high-quality water and sanitation services in the region.

ASSESSMENT OF VARIATION IN THE DETECTION AND PREVALENCE OF BLOOD PARASITES AMONG SYMPATRICALLY BREEDING GEESE IN WESTERN ALASKA, USA.

Haemosporidian parasites may impact avian health and are subject to shifts in distribution and abundance with changing ecologic conditions. Therefore, understanding variation in parasite prevalence is important for evaluating biologically meaningful changes in infection patterns and associated population level impacts. Previous research in western Alaska, US, indicated a possible increase in Leucocytozoon spp. infection between Emperor Geese (Anser canagicus) sampled in 1996 (<1%, n=134) and during 2011-12 (19.9%, 95% confidence interval [CI]: 3.0-36.8%, n=77); however, different detection methods were used for these estimates. Prior research in this same region identified a lack of Leucocytozoon spp. parasites (0%, n=117) in sympatrically breeding Cackling Geese (Branta hutchinsii minima) in 2011. We molecularly screened blood samples collected from sympatrically breeding Emperor and Cackling Geese in western Alaska during additional breeding seasons to better assess temporal and species-specific variation in the prevalence of blood parasites. We found similar prevalence estimates for Leucocytozoon spp. parasites in Emperor Goose blood samples collected in 1998 and 2014, suggesting consistent infection of Emperor Geese with blood parasites at these time points. Using samples from sympatric geese sampled during 2014, we found evidence for a higher incidence of parasites among Emperor Geese (20.3%, 95% CI: 11.8-32.7%) compared to Cackling Geese (3.6%, 95% CI: 1.1-11.0%), reinforcing the previous finding of species-specific differences in infection. Furthermore, we detected Leucocytozoon, Haemoproteus, and Plasmodium spp. blood parasites in unflighted goslings of both species, supporting the possible transmission of these parasites at western Alaska breeding grounds. Our results help to clarify that prevalence of Leucocytozoon spp. parasites have probably remained consistent among Emperor Geese breeding in western Alaska since the late 1990s and that this species may disproportionally harbor Leucocytozoon spp. compared to sympatrically breeding Cackling Geese.

Siamit: A Novel Academic-Tribal Health Partnership in Northwest Alaska.

PROBLEM: American Indians and Alaska Natives hold a state-conferred right to health, yet significant health and health care disparities persist. Academic medical centers are resource-rich institutions committed to public service, yet few are engaged in responsive, equitable, and lasting tribal health partnerships to address these challenges. APPROACH: Maniilaq Association, a rural and remote tribal health organization in Northwest Alaska, partnered with Massachusetts General Hospital and Harvard Medical School to address health care needs through physician staffing, training, and quality improvement initiatives. This partnership, called Siamit, falls under tribal governance, focuses on supporting community health leaders, addresses challenges shaped by extreme geographic remoteness, and advances the mission of academic medicine in the context of tribal health priorities. OUTCOMES: Throughout the 2019-2020 academic year, Siamit augmented local physician staffing, mentored health professions trainees, provided continuing medical education courses, implemented quality improvement initiatives, and provided clinical care and operational support during the COVID-19 pandemic. Siamit began with a small budget and limited human resources, demonstrating that relatively small investments in academic-tribal health partnerships can support meaningful and positive outcomes. NEXT STEPS: During the 2020-2021 academic year, the authors plan to expand Siamit's efforts with a broader social medicine curriculum, additional attending staff, more frequent trainee rotations, an increasingly robust mentorship network for Indigenous health professions trainees, and further study of the impact of these efforts. Such partnerships may be replicable in other settings and represent a significant opportunity to advance community health priorities, strengthen tribal health systems, support the next generation of Indigenous health leaders, and carry out the academic medicine mission of teaching, research, and service.

Gastric Cancer in Alaska Native and American Indian People Living in Alaska, 1990-2017.

INTRODUCTION: Alaska Native (AN) people experience a high burden of gastric cancer compared with other US Native and non-Native populations. Previous reports have suggested that gastric cancer in AN people occurs at a younger age and is a more aggressive pathologic type. We evaluated all cases of gastric cancer in AN people from 1990 to 2017 and compared the epidemiologic and pathologic characteristics with the gastric cancers that occurred in the same time in the US white (USW) population. METHODS: Cancer data were collected by the Alaska Native Tumor Registry and National Cancer Institute's Surveillance, Epidemiology, and End Results Program. Comparisons were performed looking at the age and sex distribution of the affected AN and USW people, as well as the cancer characteristics, including the location, stage, and pathology. RESULTS: The age distribution was significantly different between AN and USW patients (P < 0.001), with a greater proportion of AN people diagnosed younger than 40 years (11% vs 3%, P < 0.0001) and 40-59 years (37% vs 20%, P < 0.0001). In addition, a greater proportion of AN people were diagnosed with distant stage cancer (AN: 48% and USW: 35%, P < 0.0001). The age-adjusted rate of gastric cancer in the AN population was significantly higher than the USW population (20.8 vs 6.7 per 100,000 persons, P < 0.0001). Although there has been a significant decrease in the gastric cancer incidence rate in the USW population, no significant change in incidence was seen in the AN population. DISCUSSION: This study highlights the disproportionate burden of gastric cancer in the AN population. Further work is needed to address and understand this disparity.

Cost-Effectiveness of Multitarget Stool DNA Testing vs Colonoscopy or Fecal Immunochemical Testing for Colorectal Cancer Screening in Alaska Native People.

OBJECTIVE: To estimate the cost-effectiveness of multitarget stool DNA testing (MT-sDNA) compared with colonoscopy and fecal immunochemical testing (FIT) for Alaska Native adults. PATIENTS AND METHODS: A Markov model was used to evaluate the 3 screening test effects over 40 years. Outcomes included colorectal cancer (CRC) incidence and mortality, costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). The study incorporated updated evidence on screening test performance and adherence and was conducted from December 15, 2016, through November 6, 2019. RESULTS: With perfect adherence, CRC incidence was reduced by 52% (95% CI, 46% to 56%) using colonoscopy, 61% (95% CI, 57% to 64%) using annual FIT, and 66% (95% CI, 63% to 68%) using MT-sDNA. Compared with no screening, perfect adherence screening extends life by 0.15, 0.17, and 0.19 QALYs per person with colonoscopy, FIT, and MT-sDNA, respectively. Colonoscopy is the most expensive strategy: approximately $110 million more than MT-sDNA and $127 million more than FIT. With imperfect adherence (best case), MT-sDNA resulted in 0.12 QALYs per person vs 0.05 and 0.06 QALYs per person by FIT and colonoscopy, respectively. Probabilistic sensitivity analyses supported the base-case analysis. Under varied adherence scenarios, MT-sDNA either dominates or is cost-effective (ICERs, $1740-$75,868 per QALY saved) compared with FIT and colonoscopy. CONCLUSION: Each strategy reduced costs and increased QALYs compared with no screening. Screening by MT-sDNA results in the largest QALY savings. In Markov model analysis, screening by MT-sDNA in the Alaska Native population was cost-effective compared with screening by colonoscopy and FIT for a wide range of adherence scenarios.

Examining Sociodemographic Factors, Food Insecurity and Obesity of Food Pantry Clients in Alaska: A Cross Sectional Study.

Food insecurity continues to be high despite the increasing use of emergency food assistance. Research shows that food insecurity among food pantry clients is over 50-70%. Despite the high rates, there remains the paradox of people who are both food insecure and obese. Limited research has examined links between obesity, food insecurity, and food pantry clients. This cross-sectional study examined the relationship between food security, weight, and sociodemographic factors of clients at the largest food pantry in Alaska. On-site surveys were completed with 148 clients between February and March of 2018. Descriptive statistics, chi-square models, and a multivariate logistic regression were used to describe participants and determine any associations. Alaska food pantry clients are primarily over 45 years old, work at least part time, and make less than $25,000 per year. A majority of participants (n = 148) were either overweight or obese (69.6%) and food insecure (88.4%). No significant associations were found between weight and food security status. Despite the lack of statistical significance, results help understand pantry clients' demographic, food security, and weight status. Providing emergency food assistance and addressing underlying causes of food insecurity or obesity, such as the ability to access healthy food, are needed first steps.

Workers' compensation injury claims of aviation industry worker injuries in Alaska, 2014-2015.

Aviation operations in Alaska often occur in remote locations and during inclement weather. Limited infrastructure and staff in some locations often requires aviation workers to perform tasks outside of their specific job descriptions. Researchers identified workers' compensation claims as a valuable data source to characterise nonfatal injuries among Alaskan aviation workers. Keyword searches of injury claim narrative fields and industry codes were used to identify potentially aviation-related workers' compensation claims during 2014-2015. These claims were manually reviewed to verify whether aviation related and manually coded according to the US Bureau of Labour Statistics' Occupational Injury and Illness Classification System. There were 875 aviation-related injury claims accepted during 2014-2015. Ramp/baggage/cargo agents incurred the most injuries (35%), followed by mechanics/maintenance workers (15%). Among all workers, Overexertion and Bodily Reaction (40%) was most often cited as the injury event, followed by Contact with Objects and Equipment (28%), and Falls, Slips, Trips (22%). Sprains, strains, tears were the most frequent nature of injury (55%). Cargo/freight/luggage was the most frequent source of injury (24%). The 3 most frequently identified injury event types were responsible for over 90% of all injuries, which indicates that preventive interventions should be directed towards tasks rather than occupational groups.

Actual causes of death in Alaska.

We estimated 2011-2015 Alaska mortality from modifiable behavioural risk factors using relative risks, hazard ratios, and population attributable fraction estimates from a comprehensive review of peer-reviewed literature; prevalence estimates from government reports; as well as data from the Alaska Department of Environmental Conservation for 2011-2015. To identify the number of deaths attributable to specified risk factors, we used mortality data from the Alaska Division of Public Health, Health Analytics & Vital Records Section. Data included actual reported deaths of Alaska residents for 2011-2015 that matched relevant underlying International Classification of Diseases and Related Health Problems 10th Revision codes. The actual causes of death in Alaska in 2011-2015 were estimated to be overweight/physical inactivity (20% of all deaths, 26% of Alaska Native deaths), smoking (18%/18%), alcohol consumption (9%/13%), firearms (4%/4%), and drug use (3%/3%). Other actual causes of death included microbial agents (3%/4%), motor vehicles (2%/2%), and environmental pollution (1%/1%). This updated methodology reveals that overweight/physical inactivity was the leading cause of death in Alaska, followed closely by smoking. Just three preventable causes made up almost 60% of all deaths, and almost 70% of deaths among Alaska Native people, both highlighting disparities and underscoring prevention needs.

Use of sexual health services among American Indian and Alaska Native Women.

Because use of sexual health services among American Indian/Alaska Native women is understudied we: (1) examined disparities in use of sexual health services between American Indian/Alaska Native and non-Hispanic white women and (2) identified factors associated with service use among American Indian/Alaska Native women. We used data from the National Survey of Family Growth regarding the use of sexual health services collected between 2006 and 2010 from women aged 15-44 years who self-identified as American Indian/Alaska Native (n = 819) and white (n = 6,196). Weighted logistic regression models estimated the likelihood of reporting the use of sexual health services by race and factors associated with use in the American Indian/Alaska Native sample. Compared to whites, American Indian/Alaska Native women were less likely to use birth control services and more likely to use services for sexually transmitted diseases and HIV. Among American Indian/Alaska Natives, younger women were more likely to use birth control services, and women who had a higher number of sexual partners were more likely to use services for sexually transmitted diseases and HIV. Our results provide a national baseline against which to assess disparities and changes in the use of sexual health services among American Indian/Alaska Native women over time.

Injury and illness among onshore workers in Alaska's seafood processing industry: Analysis of workers' compensation claims, 2014-2015.

BACKGROUND: Alaska's onshore seafood processing industry is economically vital and hazardous. METHODS: Accepted Alaska workers' compensation claims data from 2014 to 2015 were manually reviewed and coded with the Occupational Injury and Illness Classification System and associated work activity. Workforce data were utilized to calculate rates. RESULTS: 2,889 claims of nonfatal injuries/illnesses were accepted for compensation. The average annual claim rate was 63 per 1000 workers. This was significantly higher than Alaska's all-industry rate of 44 claims per 1000 workers (RR = 1.42, 95%CI = 1.37-1.48). The most frequently occurring injuries/illnesses, were by nature, sprains/strains/tears (n = 993, 36%); by body part, upper limbs (1212, 43%); and by event, contact with objects/equipment (1020, 37%) and overexertion/bodily reaction (933, 34%). Incidents associated with seafood processing/canning/freezing (n = 818) frequently involved: repetitive motion; overexertion while handling pans, fish, and buckets; and contact with fish, pans, and machinery. CONCLUSIONS: Ergonomic and safety solutions should be implemented to prevent musculoskeletal injuries/illnesses in seafood processing.

Disparities in social determinants of health outcomes and behaviours between older adults in Alaska and the contiguous US: evidence from a national survey.

Few studies have focused on understanding how sociodemographic factors impact healthy ageing in the rapidly growing population of Alaskan older adults. Therefore, the objectives of this study are to compare the health of Alaskan older adults to those in the contiguous US, and determine how the associations differ between older adults in Alaska and the contiguous US. We abstracted 165,295 respondents age 65+ from the 2016 Behavioral Risk Factor Surveillance System. We used generalised linear models to assess the associations between sociodemographic factors and six health outcomes accounting for confounders and complex sampling. In the contiguous US, females were less likely than males to be obese (OR 0.96, 95%CI 0.96-0.97), while in Alaska, females were more likely to be obese (OR 1.24, 95%CI 1.19-1.29). In the contiguous US, Alaska Natives/American Indians were more likely than respondents of other races to be smokers (OR 1.62, 95%CI 1.60-1.63), while in Alaska, the association between race and smoking was not significant (OR 1.00, 95%CI 0.94-1.06). These differences between Alaska and the contiguous US results suggest that programs designed to reduce disparities and promote healthy behaviours may need to be tailored to meet the unique needs and challenges of older adults living in Alaska.

A Framework for Culturally Relevant Online Learning: Lessons from Alaska's Tribal Health Workers.

Culturally relevant health promotion is an opportunity to reduce health inequities in diseases with modifiable risks, such as cancer. Alaska Native people bear a disproportionate cancer burden, and Alaska's rural tribal health workers consequently requested cancer education accessible online. In response, the Alaska Native Tribal Health Consortium cancer education team sought to create a framework for culturally relevant online learning to inform the creation of distance-delivered cancer education. Guided by the principles of community-based participatory action research and grounded in empowerment theory, the project team conducted a focus group with 10 Alaska Native education experts, 12 culturally diverse key informant interviews, a key stakeholder survey of 62 Alaska Native tribal health workers and their instructors/supervisors, and a literature review on distance-delivered education with Alaska Native or American Indian people. Qualitative findings were analyzed in Atlas.ti, with common themes presented in this article as a framework for culturally relevant online education. This proposed framework includes four principles: collaborative development, interactive content delivery, contextualizing learning, and creating connection. As an Alaskan tribal health worker shared "we're all in this together. All about conversations, relationships. Always learn from you/with you, together what we know and understand from the center of our experience, our ways of knowing, being, caring." The proposed framework has been applied to support cancer education and promote cancer control with Alaska Native people and has motivated health behavior change to reduce cancer risk. This framework may be adaptable to other populations to guide effective and culturally relevant online interventions.

Dental health aides in Alaska: A qualitative assessment to improve paediatric oral health in remote rural villages.

OBJECTIVE: Isolated villages in Alaska face disparities in oral health and access to care. Dental health aides such as the primary dental health aide (PDHA) and the dental health therapist (DHAT) fill a critical role for providing dental care in Alaska. Our objective was to describe strengths and barriers to paediatric dental care for children living in remote Alaska villages from the perspectives of the community and the health care system. METHODS: This qualitative study collected data through semi-structured key informant interviews with community members (n = 19) and healthcare workers (n = 19) and focus groups with patients (n = 31 adolescents and 16 caregivers of children under 12 years) living in or providing health care to 3 remote villages in Alaska. Using an inductively developed codebook and a narrative approach, 3 researchers independently read and thematically analysed the transcripts. RESULTS: Two themes emerged: (i) PDHAs and DHATs are perceived as sustainable and strongly positioned to meet the unique dental needs of the rural communities; (ii) PDHAs and DHATs face barriers that limit their effectiveness, and their distinct roles require clarification and administrative support. CONCLUSIONS: Dental health aides, both PDHAs and DHATs, are well accepted in Alaska villages. An innate understanding of cultural norms and continuity of care are key elements driving village satisfaction. The potential exists administratively to strengthen the model with the implementation of clinical and office-system strategies to increase efficiency of the dental team. Culturally adapted implementation strategies will be critical to the successful expansion of new workforce models that are addressing health disparities.

Using time-to-event analysis to identify preconception and prenatal predictors of child protective services contact.

We examined preconception and prenatal predictors of time to first child protective services (CPS) contact among Alaska children. Data were from the Alaska Longitudinal Child Abuse and Neglect Linkage (ALCANLink) project, a population-representative data source linking 2009-2011 Alaska Pregnancy Risk Assessment Monitoring System (PRAMS) data with administrative data sources through 2015. We examined the incidence CPS contact using the Kaplan-Meier method and predictors of CPS contact using Cox proportional hazards regression. Using data from the Alaska Permanent Fund Dividend and Child Death Review, we censored children who emigrated out-of-state or died during the study period. Significant predictors included low socioeconomic status (HR = 2.23, 95% CI 1.68, 2.96), maternal smoking during pregnancy (HR = 1.87, 95% CI 1.55, 2.24), unmarried maternal marital status (HR = 1.62, 95% CI 1.31, 1.99), urban residence (HR = 1.59, 95% CI 1.32, 1.92), lower maternal education (HR = 1.54, 95% CI 1.24, 1.92), maternal experience of intimate partner violence in the 12 months before childbirth(HR = 1.32, 95% CI 1.01, 1.74), Alaska Native/American Indian race (HR = 1.40, 95% CI 1.15, 1.71), a greater number of living children (HR = 1.20, 95% CI 1.13, 1.29), a greater number of stressful life eventsin the 12 months before childbirth (HR = 1.16, 95% CI 1.11, 1.21), and younger maternal age at childbirth (HR = 0.95, 95% CI 0.93, 0.97). Use of multiple linked data sources and time-to-event analysis methods adds to the growing literature regarding predictors of CPS contact. Results suggest that assessing for and addressing clinical, social, and environmental indicators during the prenatal period may aid prevention efforts in mitigating family need for involvement with CPS.