The Impacts of Politicization on Public Health Workers: The COVID-19 Pandemic in Oregon and Montana.

CONTEXT: The contributions from the field of public health to human society are numerous and are often taken for granted. The COVID-19 pandemic thrust the largely invisible public health workforce into the public eye. Like other career civil servants at the intersection of the citizen-state encounter, reports of uncooperative, hostile, and even violent confrontations between public health workers and those they serve are on the rise. This study explores the attitudes of public health professionals in two states in the American West. METHODS: The authors conducted an anonymous web-based survey of public health professionals in Montana and Oregon one year into the COVID-19 pandemic. FINDINGS: Public health workers who responded to the survey reported beliefs that the COVID-19 pandemic was politicized by actors in the government, both major political parties, the media, and the public broadly. This politicization affected workers' abilities to do their jobs, with respondents in Montana experiencing more negative impacts than those in Oregon. CONCLUSIONS: Public health workers face growing antagonism from the public and pressure from political leaders, which poses a significant concern for the public health workforce and for communities as they prepare to address and overcome future public health challenges.

Use of Stay-at-Home Orders and Mask Mandates to Control COVID-19 Transmission - Blackfeet Tribal Reservation, Montana, June-December 2020.

COVID-19 has disproportionately affected persons who identify as non-Hispanic American Indian or Alaska Native (AI/AN) (1). The Blackfeet Tribal Reservation, the northern Montana home of the sovereign Blackfeet Nation, with an estimated population of 10,629 (2), detected the first COVID-19 case in the community on June 16, 2020. Following CDC guidance,* and with free testing widely available, the Indian Health Service and Blackfeet Tribal Health Department began investigating all confirmed cases and their contacts on June 25. The relationship between three community mitigation resolutions passed and enforced by the Blackfeet Tribal Business Council and changes in the daily COVID-19 incidence and in the distributions of new cases was assessed. After the September 28 issuance of a strictly enforced stay-at-home order and adoption of a mask use resolution, COVID-19 incidence in the Blackfeet Tribal Reservation decreased by a factor of 33 from its peak of 6.40 cases per 1,000 residents per day on October 5 to 0.19 on November 7. Other mitigation measures the Blackfeet Tribal Reservation used included closing the east gate of Glacier National Park for the summer tourism season, instituting remote learning for public school students throughout the fall semester, and providing a Thanksgiving meal to every household to reduce trips to grocery stores. CDC has recommended use of routine public health interventions for infectious diseases, including case investigation with prompt isolation, contact tracing, and immediate quarantine after exposure to prevent and control transmission of SARS-CoV-2, the virus that causes COVID-19 (3). Stay-at-home orders, physical distancing, and mask wearing indoors, outdoors when physical distancing is not possible, or when in close contact with infected or exposed persons are also recommended as nonpharmaceutical community mitigation measures (3,4). Implementation and strict enforcement of stay-at-home orders and a mask use mandate likely helped reduce the spread of COVID-19 in the Blackfeet Tribal Reservation.

COVID-19 Incidence and Mortality Among American Indian/Alaska Native and White Persons - Montana, March 13-November 30, 2020.

Geographic differences in infectious disease mortality rates have been observed among American Indian or Alaska Native (AI/AN) persons in the United States (1), and aggregate analyses of data from selected U.S. states indicate that COVID-19 incidence and mortality are higher among AI/AN persons than they are among White persons (2,3). State-level data could be used to identify disparities and guide local efforts to reduce COVID-19-associated incidence and mortality; however, such data are limited. Reports of laboratory-confirmed COVID-19 cases and COVID-19-associated deaths reported to the Montana Department of Public Health and Human Services (MDPHHS) were analyzed to describe COVID-19 incidence, mortality, and case-fatality rates among AI/AN persons compared with those among White persons. During March-November 2020 in Montana, the estimated cumulative COVID-19 incidence among AI/AN persons (9,064 cases per 100,000) was 2.2 times that among White persons (4,033 cases per 100,000).* During the same period, the cumulative COVID-19 mortality rate among AI/AN persons (267 deaths per 100,000) was 3.8 times that among White persons (71 deaths per 100,000). The AI/AN COVID-19 case-fatality rate (29.4 deaths per 1,000 COVID-19 cases) was 1.7 times the rate in White persons (17.0 deaths per 1,000). State-level surveillance findings can help in developing state and tribal COVID-19 vaccine allocation strategies and assist in local implementation of culturally appropriate public health measures that might help reduce COVID-19 incidence and mortality in AI/AN communities.

A mixed-methods analysis of logging injuries in Montana and Idaho.

BACKGROUND: Despite advances in mechanization, logging continues to be one of the most dangerous occupations in the United States. Logging in the Intermountain West region (Montana and Idaho) is especially hazardous due to steep terrain, extreme weather, and remote work locations. METHODS: We implemented a mixed-methods approach combining analyses of workers' compensation claims and focus groups to identify factors associated with injuries and fatalities in the logging industry. RESULTS: Inexperienced workers (>6 months experience) accounted for over 25% of claims. Sprain/strain injuries were the most common, accounting for 36% of claims, while fatalities had the highest median claim cost ($274 411). Focus groups identified job tasks involving felling trees, skidding, and truck driving as having highest risk. CONCLUSIONS: Injury prevention efforts should focus on training related to safe work methods (especially for inexperienced workers), the development of a safety culture and safety leadership, as well as implementation of engineering controls.

A preliminary needs assessment of American Indians who inject drugs in northeastern Montana.

BACKGROUND: Injection drug use has not been well documented in American Indians living in the USA. American Indian and Alaskan Natives (AI/ANs) show higher rates of substance use compared to the general population, and have historically been subject to a number of risk factors that are known to increase the likelihood of substance use. AI/ANs also experience increased risk for infectious diseases that are transmitted via injection drug use and/or sexual activity. Harm reduction approaches have been shown to be effective for decreasing risk of disease transmission in at-risk populations, and may be well suited for AI/AN injection drug users residing in rural reservation communities. In this study, we aimed to examine the characteristics of American Indians (AI) who use injection drugs (PWUID) in northeastern Montana to identify needs that could be addressed with harm reduction programming. METHODS: For the present study, we used a respondent-driven sampling approach to generate a sample of 51 self-identified male and female injection drug users ≥18 years of age who were American Indians living on the Fort Peck Indian Reservation. Sampling weights were applied to all analyses using Respondent-Driven Sampling Analysis Tool (RDSAT). RESULTS: There were no strong recruitment patterns by age, sex, or ethnic identity status of the recruiter or participant, but there were strong within-group recruitment patterns by location within the reservation. The majority of the sample reported initiating substance use before the age of 18. Participants reported significant risk for HIV, hepatitis, and other infectious diseases through their drug use and/or risky sexual behavior. Sixty-five percent reported having reused syringes, and 53% reported drawing from the same filter. Seventy-five percent reported inconsistent condom use during the 3 months preceding the survey, and 53% reported injecting drugs during sex during the 3 months preceding the survey. Only 66% of participants reported having been tested for HIV in the 12 months preceding the survey. The vast majority (98%) of respondents expressed interest in a harm reduction program. Seventy-six percent reported that it was easy or very easy to obtain new syringes. CONCLUSIONS: We documented several risks for blood-borne pathogens, including elevated levels of syringe reuse. Further, we documented significant interest in harm reduction interventions in the present sample of AI/AN injection drug users. Findings suggest a need for increased access to harm reduction programming for AI/AN injection drug users to reduce the transmission of infectious disease and increase access to compassionate care.

How Does Legalization of Physician-Assisted Suicide Affect Rates of Suicide?

OBJECTIVES: Several US states have legalized or decriminalized physician-assisted suicide (PAS) while others are considering permitting PAS. Although it has been suggested that legalization could lead to a reduction in total suicides and to a delay in those suicides that do occur, to date no research has tested whether these effects can be identified in practice. The aim of this study was to fill this gap by examining the association between the legalization of PAS and state-level suicide rates in the United States between 1990 and 2013. METHODS: We used regression analysis to test the change in rates of nonassisted suicides and total suicides (including assisted suicides) before and after the legalization of PAS. RESULTS: Controlling for various socioeconomic factors, unobservable state and year effects, and state-specific linear trends, we found that legalizing PAS was associated with a 6.3% (95% confidence interval 2.70%-9.9%) increase in total suicides (including assisted suicides). This effect was larger in the individuals older than 65 years (14.5%, CI 6.4%-22.7%). Introduction of PAS was neither associated with a reduction in nonassisted suicide rates nor with an increase in the mean age of nonassisted suicide. CONCLUSIONS: Legalizing PAS has been associated with an increased rate of total suicides relative to other states and no decrease in nonassisted suicides. This suggests either that PAS does not inhibit (nor acts as an alternative to) nonassisted suicide, or that it acts in this way in some individuals but is associated with an increased inclination to suicide in other individuals.

High mortality rate of unintentional poisoning due to prescription opioids in adults enrolled in Medicaid compared to those not enrolled in Medicaid in Montana.

BACKGROUND: Unintentional death due to prescription drug-related poisoning has been a growing problem nationally. Some sub-populations have been shown to be at higher risk than others. METHODS: In 2014, we matched death records to Medicaid eligibility files to determine enrollment status at the time of unintentional death from prescription opioid poisoning from 2003 to 2012 in Montana. Medicaid prescription claims for decedents were used to assess prescribing patterns and time between refills. RESULTS: The age-adjusted mortality rate per 100,000 from opioid poisoning for adults aged 18-64 years and enrolled in Medicaid at the time of death was eight times higher than the rate for non-Medicaid Montana adults (38.2 [95% CI (30.7-45.7)] vs. 4.7 [95% CI (4.1-5.3)]). Twenty-eight percent of unintentional poisoning deaths during this time frame were among Medicaid members. Only 33% of the Medicaid decedents had a claim for an opioid prescription during the month before their death. CONCLUSION: Our findings suggest that more needs to be done to address prescription opioid use in Montana. Adults enrolled in Medicaid continue to be at high risk for prescription opioid unintentional poisoning deaths. Data on prescribing practices suggest that there are opportunities to intervene and provide education on use of opioid medications for Medicaid members and prescribing providers.

Multiple pathway asbestos exposure assessment for a Superfund community.

Libby, MT, USA, was the home to workers at a historical vermiculite mining facility and served as the processing and distribution center for this industrial product that was contaminated with amphibole asbestos. Several pathways of environmental asbestos exposure to the general population have been identified. The local clinic and health screening program collects data from participants on past occupational and environmental exposures to vermiculite and asbestos. Health studies among this population have demonstrated associations between amphibole exposure and health outcomes, but critical questions regarding the nature and level of exposure associated with specific outcomes remain unanswered. The objective of this study was to develop a comprehensive exposure assessment approach that integrates information on individuals' contact frequency with multiple exposure pathways. For 3031 participants, we describe cumulative exposure metrics for environmental exposures, occupational exposures, and residents' contact with carry-home asbestos from household workers. As expected, cumulative exposures for all three occupational categories were higher among men compared with women, and cumulative exposures for household contact and environmental pathways were higher among women. The comprehensive exposure assessment strategies will advance health studies and risk assessment approaches in this population with a complex history of both occupational and environmental asbestos exposure.

Influence of exposure assessment and parameterization on exposure response. Aspects of epidemiologic cohort analysis using the Libby Amphibole asbestos worker cohort.

Recent meta-analyses of occupational epidemiology studies identified two important exposure data quality factors in predicting summary effect measures for asbestos-associated lung cancer mortality risk: sufficiency of job history data and percent coverage of work history by measured exposures. The objective was to evaluate different exposure parameterizations suggested in the asbestos literature using the Libby, MT asbestos worker cohort and to evaluate influences of exposure measurement error caused by historically estimated exposure data on lung cancer risks. Focusing on workers hired after 1959, when job histories were well-known and occupational exposures were predominantly based on measured exposures (85% coverage), we found that cumulative exposure alone, and with allowance of exponential decay, fit lung cancer mortality data similarly. Residence-time-weighted metrics did not fit well. Compared with previous analyses based on the whole cohort of Libby workers hired after 1935, when job histories were less well-known and exposures less frequently measured (47% coverage), our analyses based on higher quality exposure data yielded an effect size as much as 3.6 times higher. Future occupational cohort studies should continue to refine retrospective exposure assessment methods, consider multiple exposure metrics, and explore new methods of maintaining statistical power while minimizing exposure measurement error.

Clinician assessment for Coxiella burnetii infection in hospitalized patients with potentially compatible illnesses during Q fever outbreaks and following a health alert, Montana, 2011.

BACKGROUND: Coxiella burnetii is an endemic bacterial pathogen in the United States and the causative agent of Q fever. Two outbreaks of Q fever occurred in Montana during 2011, which led to the issuance of a health alert urging clinicians to test patients with Q fever-compatible illnesses for C. burnetii infection. METHODS: We retrospectively evaluated the medical records of patients hospitalized for fever, pneumonia, chest pain, and viral infection of unknown etiologies during the two Q fever outbreaks and following the health alert. RESULTS: A total of 103 patients were included in the analysis. Clinicians assessed<1% of patients suffering illnesses compatible with Q fever for known risk factors or C. burnetii infection. Only 1 patient had Q fever excluded as a diagnosis. CONCLUSION: Clinicians should assess for Q fever risk factors and consider the diagnosis in patients hospitalized with Q fever-compatible illnesses when the etiology of illness is unknown. Work is warranted to evaluate the effectiveness of current healthcare alert practices for zoonotic diseases.

It's all in the lens: differences in views on obesity prevention between advocates and policy makers.

BACKGROUND: Intervention strategies to reduce obesity include policy and environmental changes that are designed to provide opportunities, support, and cues to help people develop healthier behaviors. Policy changes at the state level are one way to influence access, social norms, and opportunities for better nutrition and increased physical activity among the population. METHODS: Ten states were selected for a broad variance in obesity rates and number of enacted obesity prevention policies during the years of 2006-2009. Within the selected states, a purely qualitative study of attitudes of childhood obesity policy using semistructured telephone interviews was conducted. Interviews were conducted with state policy makers who serve on public health committees. A set of six states that had more than eight childhood obesity policies enacted were selected for subsequent qualitative interviews with a convenience sample of well-established advocates. RESULTS: Policy makers in states where there was more childhood obesity policy action believed in the evidence behind obesity policy proposals. Policy makers also varied in the perception of obesity as a constituent priority. The major differences between advocates and policy makers included a disconnect in information dissemination, opposition, and effectiveness of these policies. CONCLUSIONS: The findings from this study show differences in perceptions among policy makers in states with a greater number of obesity prevention bills enacted. There are differences among policy makers and advocates regarding the role and effectiveness of state policy on obesity prevention. This presents an opportunity for researchers and practitioners to improve communication and translation of evidence to policy makers, particularly in states with low legislation.

Determining satisfaction with access and financial aspects of care for persons exposed to Libby amphibole asbestos: rural and national environmental policy implications.

Libby, Montana is a Superfund site and epicenter of one of the worst environmental disasters in the USA history in terms of asbestos-related mortality and morbidity. Perceptions of access and financial aspects of care were explored among a national cohort of persons postasbestos exposure and prior to a 2009 Public Health Emergency Declaration. Our findings indicated the Libby cohort was significantly less satisfied with access and financial aspects of care as measured by two PSQ-III scales when compared to an adult, chronically ill patient sample. Participants with higher levels of respiratory morbidity and depression had significantly lower satisfaction scores.

Does information matter? The effect of the Meth Project on meth use among youths.

Are demand-side interventions effective at curbing drug use? To the extent demand-side programs are successful, their cost effectiveness can be appealing from a policy perspective. Established in 2005, the Montana Meth Project (MMP) employs a graphic advertising campaign to deter meth use among teens. Due to the MMP's apparent success, seven other states have adopted Meth Project campaigns. Using data from the Youth Risk Behavior Surveys (YRBS), this paper investigates whether the MMP reduced methamphetamine use among Montana's youth. When accounting for a preexisting downward trend in meth use, effects on meth use are statistically indistinguishable from zero. These results are robust to using related changes of meth use among individuals without exposure to the campaign as controls in a difference-in-difference framework. A complementary analysis of treatment admissions data from the Treatment Episode Data Set (TEDS) confirms the MMP has had no discernable impact on meth use.

Potency factors for risk assessment at Libby, Montana.

We reanalyzed the Libby vermiculite miners' cohort assembled by Sullivan to estimate potency factors for lung cancer, mesothelioma, nonmalignant respiratory disease (NMRD), and all-cause mortality associated with exposure to Libby fibers. Our principal statistical tool for analyses of lung cancer, NMRD, and total mortality in the cohort was the time-dependent proportional hazards model. For mesothelioma, we used an extension of the Peto formula. For a cumulative exposure to Libby fiber of 100 f/mL-yr, our estimates of relative risk (RR) are as follows: lung cancer, RR = 1.12, 95% confidence interval (CI) =[1.06, 1.17]; NMRD, RR = 1.14, 95% CI =[1.09, 1.18]; total mortality, RR = 1.06, 95% CI =[1.04, 1.08]. These estimates were virtually identical when analyses were restricted to the subcohort of workers who were employed for at least one year. For mesothelioma, our estimate of potency is K(M) = 0.5 x 10(-8), 95% CI =[0.3 x 10(-8), 0.8 x 10(-8)]. Finally, we estimated the mortality ratios standardized against the U.S. population for lung cancer, NMRD, and total mortality and obtained estimates that were in good agreement with those reported by Sullivan. The estimated potency factors form the basis for a quantitative risk assessment at Libby.

Improvements in care and reduced self-management barriers among rural patients with diabetes.

CONTEXT: Improved preventive care and clinical outcomes among patients with diabetes can reduce complications and costs; however, diabetes care continues to be suboptimal. Few studies have described effective strategies for improving care among rural populations with diabetes. PURPOSE: In 2000, the Park County Diabetes Project and the Montana Diabetes Control Program collaboratively implemented a countywide effort, which included health systems interventions and coordinated diabetes education, to improve the quality of diabetes care. METHODS: Clinical data from the diabetes registries in 2 primary care practices, in addition to baseline and follow-up telephone surveys, were used to evaluate improvements in care, outcomes, education, and barriers to self-management. FINDINGS: In the cohort of patients, the proportion receiving the following services increased significantly from 2000 to 2003: annual foot examination (43% to 58%), influenza (30% to 53%), and pneumoccocal immunizations (39% to 70%). The median hemoglobin A1c values decreased significantly from baseline to follow-up (7.2% to 6.8%). Mean systolic and diastolic blood pressure decreased significantly over the 2 time periods (139 mmHg to 135 mmHg, and 78 mmHg to 75 mmHg, respectively). Significant decreases were also observed in barriers to self-management, including lack of knowledge (decrease from 12% to 5%), difficulties making lifestyle changes (36% to 27%), cost of monitors and test strips (25% to 16%), cost of medications (37% to 24%), and diabetes education (22% to 4%). CONCLUSIONS: Findings suggest that system changes in primary care practices and the implementation of accessible diabetes education can improve care and reduce barriers for rural patients with diabetes.

Moderate physical activity and its relationship to select measures of a healthy diet.

CONTEXT: In rural communities, physical activity may influence and predict nutritional behaviors. PURPOSE: The purpose of this investigation was to determine if an individual's stage of participation in moderate physical activity was related to select measures of a healthy diet. METHODS: Data were collected using a mail-in survey from a random sample conducted in the rural/frontier communities of Idaho, Montana, and Wyoming. A total of 6 communities, 2 from each state, were surveyed with approximately 575 surveys sent to each community. The response rate was 51.5%. FINDINGS: Regression analysis revealed that there was a significant difference (P < 05) in select measures of a healthy diet between those in the maintenance stage of moderate levels of physical activity (physically active for 6 months or more) and those in precontemplation (not currently active and with no intention of starting), contemplation (not currently active but considering starting within the next 6 months), and preparation (not currently active but taking steps to become active within the next 30 days). Those in maintenance had a healthier diet. Additionally, women, older people, those with at least some college education, and those who were employed had healthier diets. CONCLUSIONS: These results lend preliminary support to the idea that moderate physical activity could act as a gateway behavior, a behavior that, if adopted, could lead to the adoption of other healthy behaviors. However, additional research is needed to confirm the nature, if any, of this relationship.

Immunization for seniors.

Vaccine-preventable diseases remain a significant health problem for adults in the United States. Far more adults die from the complications of vaccine-preventable diseases than do children in this country. Available vaccines that are effective in preventing morbidity and mortality from these conditions are underutilized, and significant racial and ethnic disparities in rates of utilization of adult vaccines persist. A variety of important vaccine-preventable diseases affect seniors. However, influenza and pneumococcal infections stand out as being responsible for more cases and more deaths each year among seniors than all other vaccine-preventable diseases in the United States combined. Current vaccination rates for these two diseases are far short of the Healthy People 2010 target rates of 90% immunization of the population of adults aged 65 years or over. Despite state efforts to improve vaccination rates of seniors, efforts that have included regulatory and educational approaches, significant challenges remain in designing immunization programs for seniors that are universally effective.

Billings' methamphetamine epidemic. Nursing leaders frame a public health and environmental health problem.

Methamphetamine use in rural communities is at epidemic levels and constitutes a public health crisis in many parts our nation. This synthetically-derived drug is commonly manufactured in illicit laboratories in homes and has harmful consequences for both people and the environment. Three RWJ nurse Fellows collaborated on community health efforts to heighten Montana citizens' awareness of the methamphetamine problem and to leverage additional resources for the fight against drugs. The Fellows efforts, combined with the ongoing efforts of other Montana politicians and leaders, have recently led to a significant infusion of federal drug enforcement and treatment funds into the state.

North American Indian Alliance mental health needs assessment report.

The North American Indian Alliance (NAIA), located in Butte, Montana, conducted a mental health needs assessment from December, 1991 to June, 1992. The goals of this assessment were to identify unmet health needs, obtain input regarding the need for additional services, and identify barriers to providing and accessing services. Surveys of mental health service providers (n = 30) and consumers of NAIA services (n = 74) were conducted. The results of these surveys and their implications for service provision are explored.