Examining the Role of Interpersonal Violence in Racial Disparities in Breastfeeding in North Dakota (ND PRAMS 2017-2019).

BACKGROUND: The 2019 overall breastfeeding initiation rate in the US was 84.1%, yet only 76.6% of American Indian (AI) women initiated breastfeeding. In North Dakota (ND), AI women have greater exposure to interpersonal violence than other racial/ethnic groups. Stress associated with interpersonal violence may interfere with processes important to breastfeeding. We explored whether interpersonal violence partially explains racial/ethnic disparities in breastfeeding in ND. METHODS: Data for 2161 women were drawn from the 2017-2019 ND Pregnancy Risk Assessment Monitoring System. Breastfeeding questions in PRAMS have been tested among diverse populations. Breastfeeding initiation was self-report to "Did you ever breastfeed or pump breast milk to feed your new baby, even for a short period?" (yes/no). Breastfeeding duration (2 months; 6 months) was self-reported how many weeks or months of breastmilk feeding. Interpersonal violence for both 12 months before and during pregnancy based on self-report (yes/no) of violence from a husband/partner, family member, someone else, or ex-husband/partner. An "Any violence" variable was created if participants reported "yes" to any violence. Logistic regression models estimated crude and adjusted odds ratios (OR) and 95% confidence intervals (95% CI) for breastfeeding outcomes among AI and Other Race women compared to White women. Sequential models were adjusted for interpersonal violence (husband/partner, family member, someone else, ex-husband/partner, or any). RESULTS: AI women had 45% reduced odds of initiating breastfeeding (OR: 0.55, 95% CI: 0.36, 0.82) compared to white women. Including interpersonal violence during pregnancy did not change results. Similar patterns were observed for all breastfeeding outcomes and all interpersonal violence exposures. DISCUSSION: Interpersonal violence does not explain the disparity in breastfeeding in ND. Considering cultural ties to the tradition of breastfeeding and the role of colonization may provide a better understanding of breastfeeding among AI populations.

Comparing vaccination coverage of American Indian children with White children in North Dakota.

OBJECTIVES: The objective of this study was to compare immunization rates of American Indian (AI) and White children in North Dakota and identify disparities in immunization rates by race. STUDY DESIGN: The study design was to assess immunization coverage rates by race using immunization information system (IIS) data. METHODS: Data from the North Dakota Immunization Information System (NDIIS) for children aged 19-35 months during quarter four of 2014, 2015, 2016, 2017 and 2018 were used to assess and compare immunization coverage rates for AI and White children. NDIIS data were also analyzed for timeliness of vaccine administration, Vaccines for Children (VFC) status, and the number of doses still needed to be considered up to date (UTD) with routinely recommended immunizations. RESULTS: In quarter four of 2018 (Q4 2018), only 60% of AI children were UTD with the complete 4:3:1:3:3:1:4 vaccine series compared with 74.5% of White children of the same age. Fewer VFC-eligible AI children (59.1%) are UTD than VFC-eligible White children (68.7%). AI children were also more likely to be delayed at each immunization milestone, leading to fewer AI children to be UTD by 19 to 35 months of age. CONCLUSIONS: This study shows that there is a racial disparity in immunization coverage rates between AI and White children in North Dakota. Public health and private healthcare providers should work to identify and address barriers to vaccination and should implement strategies to increase immunization rates for AI children.

Disparities in Risk Factors and Birth Outcomes Among American Indians in North Dakota.

Objectives High infant mortality rates among American Indians in North Dakota contribute to a 20-year gap in average age at death compared to whites. Geographic- and race-specific health disparities data to drive policy making and interventions are not well disseminated. The current study examines prenatal risk factors and birth outcomes between American Indian and whites in North Dakota. Methods A retrospective descriptive analysis of North Dakota live births from 2007 to 2012 was conducted. Period prevalence and prevalence ratios were calculated. Results The infant mortality rate from 2010 to 2012 for infants born to American Indian women was 3.5 times higher than whites. Racial disparities existed in education, teen births, tobacco use during pregnancy, and breastfeeding initiation. Disparities widened for inadequate prenatal care, illegal drug use during pregnancy, and infant mortality from 2007-2009 to 2010-2012 and narrowed for sexually transmitted infections and alcohol use during pregnancy. Conclusions for Practice American Indians are disproportionately affected by poor pregnancy and birth outcomes in North Dakota. Future geographic-specific American Indian research is warranted to aid current and future public health interventions.

Trends and Patterns of Late and Unstaged Lung, Colorectal, Female Breast, and Prostate Cancers among American Indians in the Northern Plains, 2002-2009.

INTRODUCTION: We investigated incidence and staging patterns of prostate, female breast, lung, and colorectal cancer among American Indians/Alaska Natives (AI/ANs) and non-Hispanic Whites (NHWs) in the Northern Plains. METHODS: Cancer registry data (2002-2009) from Nebraska, North Dakota, and South Dakota were analyzed. Incidence rates were calculated and multivariate logistic regression analyses identified factors associated with unstaged versus staged and late-stage cancer cases versus early. RESULTS: The incidence rate was higher among AI/ANs than NHWs for lung cancer (92.2 vs. 60.6 per 100,000). Compared with NHWs, AI/ANs were 2.0 times more likely to receive an unstaged diagnosis and 1.2 times more likely to receive a late-stage diagnosis. AI/ANs were significantly more likely than NHWs to receive an unstaged diagnosis. DISCUSSION: Increased efforts are needed to reduce unstaged and late-stage diagnoses among Northern Plains AIs. Efforts to promote early detection of cancer should target younger AI/ANs.

Rural adolescents' access to adolescent friendly health services.

INTRODUCTION: The purpose of this study was to assess rural North Dakota adolescents' experiences in accessing adolescent-friendly health services and to examine the relationship between rural adolescents' communication with health care providers and risk behaviors. METHODS: Data are from the Rural Adolescent Health Survey (RAHS), an anonymous survey of 14- to 19-year-olds (n = 322) attending secondary schools in four frontier counties of North Dakota. Descriptive statistics were used to assess participants' access to adolescent-friendly health services characterized as accessible, acceptable, and appropriate. Logistic regressions were used to examine whether participant-reported risk behaviors predicted communication with health care providers about individual health risk behaviors. RESULTS: Rural adolescents reported high access to acceptable primary health care services but low levels of effective health care services. Participant report of engaging in high-risk behaviors was associated with having received information from health care providers about the leading causes of morbidity and mortality. DISCUSSIONS: These findings reveal missed opportunities for primary care providers in rural settings to provide fundamental health promotion to adolescents.

The impact of the 2009 Red River Flood on interpersonal risk factors for suicide.

BACKGROUND: Natural disasters are frequently associated with increases in risk factors for suicide, yet research indicates that suicide rates tend to stay the same or decrease in the wake of disasters (e.g., Krug et al., 1999). AIMS: The present research sought to shed light on this counterintuitive phenomenon by testing hypotheses derived from Joiner's (2005) interpersonal-psychological theory of suicidal behavior, which proposes that the desire to die by suicide is the result of feeling like one does not belong and feeling like one is a burden on others. During natural disasters, community members often pull together in volunteering efforts, and it was predicted that such behaviors would boost feelings of belonging and reduce feelings that one is a burden. METHODS: The present study tested these predictions in a sample of 210 undergraduate students in Fargo, North Dakota, following the 2009 Red River Flood. RESULTS: Consistent with prediction, greater amounts of time spent volunteering in flood efforts were associated with increased feelings of belongingness and decreased feelings of burdensomeness. CONCLUSIONS: The findings in the current study are consistent with the notion that communities pulling together during a natural disaster can reduce interpersonal risk factors associated with the desire for suicide.

Impact of the Red River catastrophic flood on women giving birth in North Dakota, 1994-2000.

To document changes in birth rates, birth outcomes, and pregnancy risk factors among women giving birth after the 1997 Red River flood in North Dakota. We analyzed detailed county-level birth files pre-disaster (1994-1996) and post-disaster (1997-2000) in North Dakota. Crude birth rates and adjusted fertility rates were calculated. The demographic and pregnancy risk factors were described among women delivering singleton births. Logistic regression was conducted to examine associations between the disaster and low birth weight (<2,500 g), preterm birth (<37 weeks), and small for gestational age infants adjusting for confounders. The crude birth rate and direct-adjusted fertility rate decreased significantly after the disaster in North Dakota. The proportion of women giving birth who were older, non-white, unmarried, and had a higher education increased. Compared to pre-disaster, there were significant increases in the following maternal measures after the disaster: any medical risks (5.1-7.1%), anemia (0.7-1.1%), acute or chronic lung disease (0.4-0.5%), eclampsia (0.3-2.1%), and uterine bleeding (0.3-0.4%). In addition, there was a significant increase in births that were low birth weight (OR 1.11, 95% CI 1.03-1.21) and preterm (OR 1.09, 95% CI 1.03-1.16) after adjusting for maternal characteristics and smoking. Following the flood, there was an increase in medical risks, low birth weight, and preterm delivery among women giving birth in North Dakota. Further research that examines birth outcomes of women following a catastrophic disaster is warranted.

Assessing health-related quality of life in Northern Plains American Indians: prominence of physical activity as a health behavior.

Associations of behavioral health risks and healthy behaviors with self-reported health-related quality of life measures were investigated in a Northern Plains American Indian sample. Participants were surveyed in person using the Behavioral Risk Factor Surveillance Survey. The results showed that regular physical activity was significantly associated with better self-reported overall health, fewer mentally unhealthy and activity limitation days in the past 30 days, and with a greater number of good health days.

Assessing health status, behavioral risks, and health disparities in American Indians living on the northern plains of the U.S.

OBJECTIVE: We assessed health status and behavioral risks in American Indians (AIs) from rural, northern plains reservation communities. METHODS: AI interviewers from the communities administered the core and optional modules of the Behavioral Risk Factor Surveillance System (BRFSS) to 404 AI adults randomly selected from housing lists from four AI tribal communities located on the northern plains of the U.S. The BRFSS interview assessed several health functioning areas including medical conditions, preventive screenings, and behavioral risks. We measured health disparities by comparing the AI sample data with a northern plains statewide (North Dakota) sample and a U.S. national sample. We compared outcomes with BRFSS statewide (North Dakota) and U.S. national data from telephone-based interviews. RESULTS: AI participants showed a significantly greater prevalence of diabetes, coronary heart disease, myocardial infarction, smoking, obesity, and heavy alcohol use than either the regional or national samples. They also reported being less likely to engage in leisure-time physical activity and to have had age-appropriate preventive screenings for several diseases including colorectal cancer, prostate cancer, breast cancer, and cardiovascular disease. CONCLUSIONS: Face-to-face interviews conducted by AI community members are an effective means of gathering health information about AIs living in rural, reservation communities. AIs living in these communities on the northern plains have a much higher prevalence of many health-risk behaviors and some medical conditions than are found in the general population. Improved health-care access, better preventive screenings, and culturally appropriate community-based health promotion programs and policies should be examined as possible ways to reduce health disparities.

Considerations in the care of older adult with chronic kidney disease.

The incidence of renal disease is increasing at alarming rates. Older adults with co-morbid conditions are at increased risk for end stage renal disease with the resulting need for renal replacement therapy. Nurses who care for the older adult must know how chronic kidney disease will affect the older adult and must be able to provide compassionate care at the end stage of life.

Statewide awareness study on personal risks of cardiovascular disease in women: a go red North Dakota study.

General awareness of cardiovascular disease (CVD) as the leading cause of death for women and knowledge of CVD risk factors have increased in the last 10 years. Whether this greater general awareness and knowledge leads to improved risk assessment on a personal level remains uncertain. Therefore, the purpose of this study was to measure the knowledge of CVD risk factors and determine the level of personal CVD risk-factor awareness among female public employees of North Dakota, ND, USA. A 30-item, pretested, standardized questionnaire was adapted from previous American Heart Association (AHA) nationwide surveys to measure awareness of the AHA's Go Red For Women movement and cardiovascular health. The online survey was completed by 1044 women, with most of the participants ( approximately 90%) reported as being aware that heart disease was the leading cause of death for women in the USA, which is much higher than the national average. Nearly all the participants (97.3%) correctly recognized the Go Red 'Red Dress' symbol, and knew that it relates to women and heart disease. The prevalence of individual CVD risk awareness was high for blood pressure (82.2%) and moderately high for cholesterol (67%). Much lower rates of CVD awareness were reported for blood glucose (40.8%) and BMI (29.4%). Along with age and certain socioeconomic factors, awareness of any one CVD risk factor was strongly associated with awareness of other CVD risk factors. It is worth mentioning that the participants with favorable demographics and background characteristics and with a high general awareness may also have low personal awareness of certain CVD risk factors. This low personal awareness lessens one's perceived susceptibility to CVD, which in turn reduces the likelihood of adopting preventive action to decrease personal risk of CVD. Future awareness programs should concentrate on improving individual risk awareness, particularly of blood glucose and BMI, as a means of improving behavior towards better cardiovascular health.

Underride safety protection: benefit-cost assessment of rear-impact guards for the North Dakota farm truck fleet.

OBJECTIVE: The North Dakota Legislature recently passed a law exempting the state's agricultural truck fleet from a federal safety program requirement for rear-guard equipment on large trucks. This equipment has been shown to reduce crash severity when a passenger vehicle collides with the rear of the truck. This study uses truck fleet, truck crash, and injury severity data to estimate the public safety benefit derived from passenger-vehicle underride protection during rear-end crashes involving large agricultural trucks in North Dakota. METHODS: A benefit-cost analysis of crash injury avoidance is developed based on the frequency and severity of rear-end truck collisions in North Dakota between 2001 and 2007. RESULTS: The injury avoidance benefits and commercial vehicle safety grant benefits are estimated to be $11.4 to $20.2 million during the seven-year depreciable truck life. CONCLUSION: The public safety benefits for rear-impact guards are higher than the estimated lifetime cost for the equipment and maintenance of $8.1 million.

Casino gambling among older adults in North Dakota: a policy analysis.

This article examined social issues surrounding casino gambling among older adults both nationally and in the state of North Dakota. An exploratory review of gambling trends among older adults and an examination of policies to protect older gamblers revealed that older adults are targeted by the gaming industry as a lucrative market (Singh et al. J Retail Leisure Property 2007, 6(1):61-68). The authors used the national literature to frame their qualitative study, which explored gambling issues among older adults in North Dakota from the perspective of six counselors trained in gambling addiction who provide treatment services in the state. Findings indicated that relatively few policies existed at the state and national levels to protect older, more vulnerable adults who gamble. Further, the six casinos in North Dakota were viewed as very effective in marketing their casino gaming opportunities to older citizens by the gambling treatment providers interviewed. Additionally, barriers to gambling addiction treatment involved lack of available services and distance to receive services in this rural state. Based on the findings of this study, social policy changes which could lead to increased protection for older adult gamblers in the state were included.

A Bayesian approach to assess heart disease mortality among persons with diabetes in the presence of missing data.

Some states' death certificate form includes a diabetes yes/no check box that enables policy makers to investigate the change in heart disease mortality rates by diabetes status. Because the check boxes are sometimes unmarked, a method accounting for missing data is needed when estimating heart disease mortality rates by diabetes status. Using North Dakota's data (1992-2003), we generate the posterior distribution of diabetes status to estimate diabetes status among those with heart disease and an unmarked check box using Monte Carlo methods. Combining this estimate with the number of death certificates with known diabetes status provides a numerator for heart disease mortality rates. Denominators for rates were estimated from the North Dakota Behavioral Risk Factor Surveillance System. Accounting for missing data, age-adjusted heart disease mortality rates (per 1,000) among women with diabetes were 8.6 during 1992-1998 and 6.7 during 1999-2003. Among men with diabetes, rates were 13.0 during 1992-1998 and 10.0 during 1999-2003. The Bayesian approach accounted for the uncertainty due to missing diabetes status as well as the uncertainty in estimating the populations with diabetes.

Communicating the risks of bioterrorism and other emergencies in a diverse society: a case study of special populations in North Dakota.

In the event that terrorists use air, water, or food to deliver destructive agents to civilian populations, some groups and populations may be disproportionately at risk and have unique communications needs. Bioterrorism represents an even greater national public health threat if the nation's preparedness and readiness plans do not address the needs and perspectives of, for example, low-income residents, racially and ethnically diverse communities, and other "special populations". The objective of this study was to develop communications strategies to reach special populations in North Dakota before, during, and after a bioterrorism attack or other crisis. To achieve the study objectives, the investigators used telephone interviews and telephone focus groups with organizations that represented special populations. Areas of inquiry included attitudes and concerns about crises, sources of information used and those identified as most credible, methods to reach people during a crisis event, and awareness of and attitudes about the agencies and organizations that affect risk communications.

The attention-deficit hyperactivity disorder paradox: 2. Phenotypic variability in prevalence and cost of comorbidity.

The objective of this study was to use population-based data to estimate the cost and phenotypic variation of conditions comorbid with attention-deficit hyperactivity disorder (ADHD). The North Dakota Department of Health's Claims Database was used to estimate the administrative prevalence, rates of comorbidity, and cost of care for subjects with ADHD. The case population was 7745 children. We then examined the 10 most frequent comorbidities for a defined condition in the International Classification of Diseases-9th edition (ICD-9). The observed prevalence of general health conditions was 12 to 70% less than expected. The presence of a comorbid condition resulted in increases in costs of care of dollar 381 to dollar 731 per case per year. The observed prevalence of comorbid mental health conditions was 97 to 5286% higher than expected. The prevalence of conditions comorbid with ADHD varies widely, with rates of general medical conditions decreased and rates of most mental disorders increased. The costs for comorbidity with general health conditions were offset by large decreases in prevalence rates compared with controls. We identified an ADHD paradox: decreased rates of comorbid general health conditions and increased rates of comorbid mental disorders. Further research on comorbidity in ADHD is required.

Children and adolescents with attention deficit-hyperactivity disorder: 1. Prevalence and cost of care.

The objective of this study was to use population-based data to estimate the prevalence and cost of treatment for attention-deficit hyperactivity disorder (ADHD). The North Dakota Department of Health Claims Database was used to estimate the administrative prevalence, annual cost of care per case, and total annual cost of care for subjects with ADHD compared with controls. The case population was 7745, and the mean prevalence rate was 3.9%, with a peak prevalence at 10 years of age. For children with ADHD, the annual cost of care was 649 dollars compared with that of controls at 495 dollars. Cost of care attributable to ADHD was 649 dollars - 495 dollars = 54 dollars (31%). Utilization by children with ADHD with publicly funded payers was increased 25 to 175% over that of children with privately funded coverage. In North Dakota, the annual cost of care for children with ADHD was 5.1 million dollars, 5.6% of all health care costs for children. The annual attributable cost of care was 1.79 million dollars. Thus, 1.9% of total health expenditures for children was attributable to ADHD. In the United States, the cost of care attributable to children with ADHD would be 2.15 billion dollars annually.

An assessment of the recidivism rates of substantiated and unsubstantiated maltreatment cases.

OBJECTIVE: This study assembles information about the large number of maltreatment reports that are determined by social services to be unsubstantiated. Specifically, we assess whether the status of a maltreatment case (substantiated vs. unsubstantiated) has implications for recidivism. Recidivism rates for substantiated and unsubstantiated maltreated juveniles were also compared to juvenile offenders. METHOD: Juvenile court records for 15,812 juveniles were assessed over a 3 year period. The data included 2558 maltreatment cases. Fifty-four percent of these cases were unsubstantiated. Logistic regression analysis was employed to assess the probability of recidivism based on time one referral status. RESULTS: Youth whose maltreatment allegations were unsubstantiated had significantly lower odds of recidivating than abused youth. Having a case recorded as unsubstantiated lowered a youth's odds of subsequent offending by 55% relative to being abused. The probability of recidivating was highest for juvenile offenders, followed in order by maltreated youth and youth whose reports were unsubstantiated. DISCUSSION: This is one of the first studies to examine the court histories of substantiated and unsubstantiated maltreatment cases. If the subsequent outcomes following maltreatment investigations are used as an indicator of seriousness, our results suggest that assessment caseworkers are successfully sorting out the serious from the less serious cases.

Underutilization of breast-conserving therapy in a predominantly rural population: need for improved surgeon and public education.

Though breast-conserving therapy (BCT) was first recommended as the preferred treatment for women with early-stage breast cancer in 1990, little is known about the factors influencing or limiting the use of BCT in rural women. We retrospectively surveyed all surviving patients (227) referred to the Roger Maris Cancer Center over a 2-year period. Disease characteristics were verified by the tumor registry and random chart review. Responses were obtained from 171 patients (75%), a median of 26 months from diagnosis. The majority of patients were from rural areas; only 32% resided in towns with a population greater than or equal to 15,000. Thirty-five percent of those patients meeting published criteria had BCT. Patients who underwent BCT were younger (mean age 56.8 vs. 62.5, P = 0.01), more likely to have benign axillary lymph nodes (82% vs. 64%, P = 0.008), and more likely to be employed away from the home (66% vs. 44%, P = 0.01) than patients who underwent mastectomy (MRM). Distance from the nearest radiation facility did not affect treatment decisions (mean: 59.5 miles BCT vs. 52.6 miles MRM). Most patients (83%) ranked their surgeon as the most important source of information about treatment options. Perceived surgical recommendations were generally followed. Only three patients who felt their surgeon recommended MRM underwent BCT; eleven patients chose MRM though they believed their surgeon recommended BCT. The choice of local therapy is predominantly a surgeon-driven process; logistical barriers unique to a rural population had little impact. Unfortunately, many surgeons continue to apply much more stringent criteria when recommending BCT than those in published guidelines.