Pre-Pandemic Landscape of the Oklahoma Public Health Workforce: A Case Study From the Region 6 Training Needs Assessment Survey, 2019.

CONTEXT: The COVID-19 pandemic highlighted the need for a well-trained public health workforce prior to the public health crisis. Public health training centers regularly assess workforce needs and their pre-pandemic data play vital roles in guiding public health workforce development beyond the crisis. PROGRAM: In 2019, Oklahoma partners of the Region 6 South Central Public Health Training Center (R6SCPHTC) co-conducted an online survey of the public health workforce located in the Health Resources & Services Administration Region 6. IMPLEMENTATION: Between March and April, the R6SCPHTC collected 503 surveys, including 201 surveys from Oklahoma. Questions inquired about demographic and workforce characteristics, work contexts, training needs and interests, training access and logistics, and knowledge of R6SCPHTC online resources. EVALUATION: Key findings included that two-thirds of the pre-pandemic Oklahoma public health workforce consisted of employees age 40 or older with few holding public health or medical degrees. The majority of respondents worked for health departments and Tribes, and almost half were frontline workers. Although at least half of the participants interested in training on public health activities and topics were familiar with them, confidence in their abilities related to these activities and topics was expressed by less than half. Qualitative data provided details on training needs addressed quantitatively and described new training areas. Survey participants expressed interest in diverse training delivery methods and technological devices. Most respondents were not familiar with the free trainings available through the R6SCPHTC. DISCUSSION: Similar to the regional and national public health workforce, Oklahoma's workforce needed training and support already before COVID-19. Time and resources need to be invested into the current and future workforce. While addressing priority public health skills and topics remains important, training on current and emerging topics is needed. Providing accessible trainings with expanded content will prepare Oklahoma's public health workforce for the future.

Analysis of Oklahoma amputation trends and identification of risk factors to target areas for limb preservation interventions.

OBJECTIVE: Annual trends of lower extremity amputation due to end-stage chronic disease are on the rise in the United States. These amputations are leading to massive expenses for patients and the medical system. In Oklahoma, we have a high-risk population because access to care is low, the number of uninsured is high, cardiovascular health is poor, and our overall health care performance is ranked 50th in the country. But we know little about Oklahomans and their risk of limb loss. It is, therefore, imperative to look closely at this population to discover contemporary rates, trends, and state-specific risk factors for amputation due to diabetes and/or peripheral arterial disease (PAD). We hypothesize that state-specific groups will be identified as having the highest risk for limb loss and that contemporary trends in amputations are rising. To create implementable solutions to limb preservation, a baseline must be set. METHODS: We conducted a 12-consecutive-year observational study using Oklahoma's hospital discharge data. Discharges among patients 20 years or older with a primary or secondary diagnosis of diabetes and/or PAD were included. Diagnoses and amputation procedures were identified using International Classification of Disease-9 and -10 codes. Amputation rates were calculated per 1000 discharges. Trends in amputation rates were measured by annual percentage changes (APC). Prevalence ratios evaluated the differences in amputation rates across demographic groups. RESULTS: Over 5,000,000 discharges were identified from 2008 to 2019. Twenty-four percent had a diagnosis of diabetes and/or PAD. The overall amputation rate was 12 per 1000 discharges for those with diabetes and/or PAD. Diabetes and/or PAD-related amputation rates increased from 8.1 to 16.2 (APC, 6.0; 95% confidence interval [CI], 4.7-7.3). Most amputations were minor (59.5%), and although minor, increased at a faster rate compared with major amputations (minor amputation APC, 8.1; 95% CI, 6.7-9.6 vs major amputation APC, 3.1; 95% CI, 1.5-4.7); major amputations were notable in that they were significantly increasing. Amputation rates were the highest among males (16.7), American Indians (19.2), uninsured (21.2), non-married patients (12.7), and patients between 45 and 49 years of age (18.8), and calculated prevalence ratios for each were significant (P = .001) when compared within their respective category. CONCLUSIONS: Amputation rates in Oklahoma have nearly doubled in 12 years, with both major and minor amputations significantly increasing. This study describes a worsening trend, underscoring that amputations due to chronic disease is an urgent statewide health care problem. We also present imperative examples of amputation health care disparities. By defining these state-specific areas and populations at risk, we have identified areas to pursue and improve care. These distinctive risk factors will help to frame a statewide limb preservation intervention.

Rural cancer disparities from Oklahoma cancer and vital records registries 2016-2020.

OBJECTIVES: Compared to Oklahoma, 33 states have higher all-cause cancer incidence rates, but only three states have higher all-cause cancer mortality rates. Given this troubling gap between Oklahoma's cancer incidence and mortality rankings, in-depth examination of cancer incidence, staging, and mortality rates among this state's high-risk populations is warranted. This study provides in-depth information on overall and cause-specific cancer incidence and mortality for the rural and urban Oklahoma populations classified by Rural-Urban Continuum Codes (RUCC). METHODS: Data were publicly available and de-identified, accessed through Oklahoma Statistics on Health Available for Everyone (OK2SHARE). Statistical analysis included calculating age-specific rates, age-adjusted rates, and percentages, as well as assessing temporal patterns using average annual percent change with 95 % confidence intervals determined by Joinpoint regression analysis. FINDINGS: Urban areas had a higher proportion of female breast cancer cases, while large and small rural areas had higher rates of lung and bronchus cancer. Urban residents were more likely to have private insurance and less likely to have Medicare compared to rural residents. Cancer incidence rates increased with age, and men had higher mortality rates than women. Lung and bronchus cancer was the leading cause of cancer death, with lower rates in urban areas compared to rural areas. CONCLUSIONS: Findings demonstrate the need to improve the early detection of cancer among the rural populations of Oklahoma. Additionally, the high mortality rates for most types of cancer experienced by the state's rural population underscores the need to improve cancer detection and treatment in these locations.

Evaluation of WIC Online Ordering during the COVID-19 Pandemic: Evidence from an Oklahoma Grocery Store Chain.

The COVID-19 pandemic is worsening the disparities in food access in the United States. As consumers have been increasingly using grocery online ordering services to limit their exposure to the COVID-19 virus, participants of federal nutrition assistance programs lack the online benefit redemption option. With the support of the US Department of Agriculture (USDA), retailers are pilot-testing online food benefit ordering in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). By combining the Oklahoma WIC administrative data, the online ordering data from a grocery store chain in Oklahoma, and the COVID-19 data in Oklahoma, this study examines how WIC participants responded to the online food benefit ordering option and how their adoption of online ordering was associated with the COVID-19 incidence. Results show that from July to December 2020, 15,171 WIC households redeemed WIC benefits at an Oklahoma chain store, but only 819 of them adopted online ordering. They together completed 102,227 online orders, which accounted for 2.7% of the store visits and 2.6% of the monetary value of WIC redemptions at these stores. There was no significant relationship between WIC online ordering adoption and COVID-19 incidence in Oklahoma.

Geographic and social economic disparities in the risk of exposure to ambient air respiratory toxicants at Oklahoma licensed early care and education facilities.

BACKGROUND: Early life exposures to hazardous air pollutants has been associated with adverse asthma-related outcomes. Neighborhood-level social and economic factors play an essential role in the distribution of hazardous air pollutants and children spend a substantial amount of time at early care and education (ECE) facilities. While the indoor air quality of these facilities has been described, particularly for criteria air pollutants such as volatile organic compounds and particulate matter, little is known about the ambient air quality of ECE facilities. OBJECTIVES: We conducted a cross-sectional study to estimate the ambient air quality of Oklahoma licensed ECE facilities and to explore associations between ambient air quality and select geographic predictors. METHODS: We estimated ambient air quality using the total respiratory hazard quotient from the National Air Toxics Assessment according to the geographical location of licensed Oklahoma ECE facilities (N = 3184). We then determined whether urban and rural ECE facilities' air respiratory toxicant exposure risk differed by ECE facilities' neighborhood-level social and economic inequities including: 1) racial-ethnic minority community, 2) neighborhood socioeconomic status, and 3) residential segregation. RESULTS: Urban ECE facilities in Hispanic segregated counties were five times more likely to be at risk of high air respiratory exposure, adjusted for integrated urban counties (p < 0.0001, 95% CI [3.824, 7.699]). Rural ECE facilities in African American segregated counties were nine times more likely to be at risk of high air respiratory toxicant exposure, adjusted for integrated rural counties (p < 0.0001, 95% CI [5.641, 15.928]). CONCLUSION: We found geographically and socially disparate patterns of higher exposures to ambient air respiratory toxicants at Oklahoma ECE facilities. Safer siting policies and interventions are needed to mitigate air respiratory toxicant exposures, which may help to reduce asthma control disparities and improve respiratory health outcomes in Oklahoma ECE facilities.

The Epidemiology of COVID-19 by Race/Ethnicity in Oklahoma City-County, Oklahoma (12 March 2020-31 May 2021).

We aimed to better understand the racially-/ethnically-specific COVID-19-related outcomes, with respect to time, to respond more effectively to emerging variants. Surveillance data from Oklahoma City-County (12 March 2020-31 May 2021) were used to summarize COVID-19 cases, hospitalizations, deaths, and COVID-19 vaccination status by racial/ethnic group and ZIP code. We estimated racially-/ethnically-specific daily hospitalization rates, the proportion of cases hospitalized, and disease odds ratios (OR) adjusting for sex, age, and the presence of at least one comorbidity. Hot spot analysis was performed using normalized values of cases, hospitalizations, and deaths generated from incidence rates per 100,000 population. During the study period, there were 103,030 confirmed cases, 3457 COVID-19-related hospitalizations, and 1500 COVID-19-related deaths. The daily 7-day average hospitalization rate for Hispanics peaked earlier than other groups and reached a maximum (3.0/100,000) in July 2020. The proportion of cases hospitalized by race/ethnicity was 6.09% among non-Hispanic Blacks, 5.48% among non-Hispanic Whites, 3.66% among Hispanics, 3.43% among American Indians, and 2.87% among Asian/Pacific Islanders. COVID-19 hot spots were identified in ZIP codes with minority communities. The Hispanic population experienced the first surge in COVID-19 cases and hospitalizations, while non-Hispanic Blacks ultimately bore the highest burden of COVID-19-related hospitalizations and deaths.

Inequalities in Tobacco Retailer Compliance Violations Across the State of Oklahoma, 2015-2019.

OBJECTIVE: To evaluate the relationship between compliance check violations, and characteristics of the tobacco retailer and neighborhood social vulnerability in Oklahoma. DESIGN: This cross-sectional study utilized the US Food and Drug Administration (FDA) Compliance Check Inspections of Tobacco Product Retailers database for 2015-2019. These data were combined with Neighborhood social vulnerability variables using the Centers for Disease Control and Prevention (CDC) Social Vulnerability Index. SETTING: The setting of this study is the state of Oklahoma, USA. OUTCOME MEASURES: The outcome variable for this analysis was whether a sale was made to the youth during the compliance check (e.g., violation; yes/no) regardless of the outcome of the violation, and number of violations per a retailer. RESULTS: We observed a strong association between having a violation and retailer store type, after controlling for socioeconomic vulnerability and percentage of mobile homes. The proportion of a tobacco retailer's violations also varied by store type. CONCLUSIONS: More targeted enforcements and retailer education by store type may be necessary to increase compliance.

American Indian and Non-Hispanic White Midlife Mortality Is Associated With Medicaid Spending: An Oklahoma Ecological Study (1999-2016).

Objective: A one third reduction of premature deaths from non-communicable diseases by 2030 is a target of the United Nations Sustainable Development Goal for Health. Unlike in other developed nations, premature mortality in the United States (US) is increasing. The state of Oklahoma suffers some of the greatest rates in the US of both all-cause mortality and overdose deaths. Medicaid opioids are associated with overdose death at the patient level, but the impact of this exposure on population all-cause mortality is unknown. The objective of this study was to look for an association between Medicaid spending, as proxy measure for Medicaid opioid exposure, and all-cause mortality rates in the 45-54-year-old American Indian/Alaska Native (AI/AN45-54) and non-Hispanic white (NHW45-54) populations. Methods: All-cause mortality rates were collected from the US Centers for Disease Control & Prevention Wonder Detailed Mortality database. Annual per capita (APC) Medicaid spending, and APC Medicare opioid claims, smoking, obesity, and poverty data were also collected from existing databases. County-level multiple linear regression (MLR) analyses were performed. American Indian mortality misclassification at death is known to be common, and sparse populations are present in certain counties; therefore, the two populations were examined as a combined population (AI/NHW45-54), with results being compared to NHW45-54 alone. Results: State-level simple linear regressions of AI/NHW45-54 mortality and APC Medicaid spending show strong, linear correlations: females, coefficient 0.168, (R2 0.956; P < 0.0001; CI95 0.15, 0.19); and males, coefficient 0.139 (R2 0.746; P < 0.0001; CI95 0.10, 0.18). County-level regression models reveal that AI/NHW45-54 mortality is strongly associated with APC Medicaid spending, adjusting for Medicare opioid claims, smoking, obesity, and poverty. In females: [R2 0.545; (F)P < 0.0001; Medicaid spending coefficient 0.137; P < 0.004; 95% CI 0.05, 0.23]. In males: [R2 0.719; (F)P < 0.0001; Medicaid spending coefficient 0.330; P < 0.001; 95% CI 0.21, 0.45]. Conclusions: In Oklahoma, per capita Medicaid spending is a very strong risk factor for all-cause mortality in the combined AI/NHW45-54 population, after controlling for Medicare opioid claims, smoking, obesity, and poverty.

Adverse Childhood Experiences, Other Psychosocial Sources of Adversity, and Quality of Life in Vulnerable Primary Care Patients.

INTRODUCTION: Adults who had adverse childhood experiences (ACEs) have increased risk of negative health outcomes. Despite the prevalence of ACEs, literature is scarce on quality of life (QOL) and ACEs in disadvantaged primary care populations. OBJECTIVE: To examine the prevalence of ACEs and association with chronic health problems and QOL in disadvantaged primary care patients in Oklahoma. METHODS: During a primary care visit, adults completed a questionnaire measuring demographics, ACEs, current health status and well-being, sources of support and adversity, and QOL. A physician investigator reviewed participants' health records, recording the incidence of 32 diagnoses commonly associated with chronic health problems. RESULTS: The survey was completed by 354 patients. Forty-three percent received disability benefits and 71% were unemployed. More than 37% reported 4 or more ACEs, and 35.5% had 0 or 1 ACE.The amount of health problems ranged from 0 to 11 and increased with the number of reported ACEs. The mean number of health problems for each ACE level was as follows: ACEs 0 to 1 had 3.01 problems (95% confidence interval = 2.96-3.88), ACEs 2 to 3 had 3.42 problems (95% confidence interval = 2.96-3.88), and ACEs 4 and above had 4.18 problems (95% confidence interval = 3.72-4.64). ACEs were significantly related to QOL. CONCLUSION: This disadvantaged primary care population had high numbers of ACEs. ACEs correlated with increasing numbers of health problems and worse QOL. Enhanced awareness and action are needed to reduce health disparities and improve outcomes in similar populations.

Medical Expenditures Associated With Diabetes Among Adult Medicaid Enrollees in Eight States.

INTRODUCTION: Little information is available on state-specific financial burdens of diabetes in the Medicaid population, yet such information is essential for state Medicaid programs to plan diabetes care and evaluate the benefits of diabetes prevention. We estimated medical expenditures associated with diabetes among adult Medicaid enrollees in 8 states. METHODS: We analyzed the latest available 2012 CMS Medicaid claims data for 1,193,811 adult enrollees aged 19-64 years in 8 states: Alabama, California, Connecticut, Florida, Illinois, Iowa, New York, and Oklahoma. For each state, we stratified the study population by Medicaid eligibility criteria: disability and nondisability. For each group, we estimated per capita annual medical expenditures on outpatient care, inpatient care, and prescription drugs by using a 2-part model, adjusted for age, sex, race/ethnicity, and comorbidities. We calculated the expenditures associated with diabetes as the difference in predicted expenditures for enrollees with and without diabetes. Analyses were done in 2017. RESULTS: For disability-based enrollees, the estimated total per capita annual diabetes expenditures ranged from $6,183 in Alabama to $15,319 in New York (all P < .001). For nondisability-based enrollees, the corresponding estimates ranged from $4,985 in Alabama to $15,366 in New York (all P < .001). The proportion of individual components varied by state and eligibility criteria. CONCLUSION: Medical expenditures associated with diabetes among adults on Medicaid were substantial and varied across studied states. Our estimates can be used by the 8 state Medicaid programs to prepare health care resources needed for diabetes care and assess the financial benefits of diabetes prevention programs.

Overview of Prescription Opioid Deaths in the Oklahoma State Medicaid Population, 2012-2016.

BACKGROUND: Medicaid members are predisposed to unintentional prescription opioid overdose. However, little is known about their individual risk factors. OBJECTIVES: To describe demographic and clinical characteristics, medical utilization, opioid use, concurrent use of benzodiazepines, risk factors, and substances involved in death for Oklahoma's Medicaid members who died of unintentional prescription opioid poisoning. SUBJECTS: Decedents who were Medicaid eligible in Oklahoma during the year of death, had an opioid recorded in cause of death, and had ≥1 opioid prescription claim between January 1, 2011 and June 30, 2016 were cases. Controls were living Medicaid members and were matched 3:1 to cases through propensity score matching. MEASURES: Demographics, clinical characteristics, and medical/pharmacy utilization were examined in the 12 months before the index date. RESULTS: Of 639 members with fatal unintentional prescription opioid overdoses, 321 had ≥1 opioid prescription claim in the year before death; these were matched to 963 controls. Compared with controls, decedents had significantly greater proportions of nonopioid substance use disorders, opioid abuse/dependence, hepatitis, gastrointestinal bleeding, trauma not involving motor vehicle accidents, nonopioid poisonings, and mental illness disorders. Decedents had significantly higher daily morphine milligram equivalent doses (67.2±74.4 vs. 47.2±50.9 mg) and greater opioid/benzodiazepine overlap (70.4% vs. 35.9%). Benzodiazepines were involved in 29.3% of deaths. CONCLUSIONS: Several comorbidities indicative of opioid use disorder and greater exposure to opioids and concomitant benzodiazepines were associated with unintentional prescription opioid overdose fatalities. Prescribers and state agencies should be aware of these addressable patient-level factors among the Medicaid population. Targeting these factors with appropriate policy interventions and education may prevent future deaths.

Effects of primary care physician density, urologist presence, and insurance status on stage of diagnosis for urologic malignancies.

OBJECTIVE: To evaluate effects of PCP density, insurance status, and urologist presence on stage of diagnosis for urologic malignancies. Cancer stage at diagnosis is an important outcome predictor. Studies have shown an inverse relationship to primary care physician (PCP) density and insurance coverage with stage of cancer diagnosis. METHODS: Data was obtained from OK2Share, an Oklahoma Central Cancer Registry, for bladder, kidney, and prostate cancer from 2000 to 2010. Physician data was obtained through the State Licensing Board. The 2010 national census was used for population data. High PCP density was defined as greater than or equal to the median value: 3.17 PCP/10,000 persons. Chi-square and multivariate logistic regressions were used to analyze effects of PCP density, insurance status, and urologist presence on advanced stage diagnosis. RESULTS: 27,086 patients were identified across 77 counties. As PCP density increased by 1 PCP/10,000 persons, the odds ratios (OR) of an advanced stage at diagnosis were 0.383, 0.468, 0.543 for bladder, kidney, and prostate cancer respectively. Compared to private insurance, being uninsured had OR of 1.61 and 2.45 respectively for kidney and prostate cancers. The OR of an advanced stage diagnosis for bladder and prostate cancer were 3.77 and 1.73, respectively, in counties with a urologist. CONCLUSIONS: Increased PCP density and insurance coverage reduced the odds of an advanced diagnosis. Implementation of policies to improve access to healthcare including through increasing PCP density and reducing the number of uninsured patients should result in diagnosis at an earlier stage, which will likely improved cancer-related outcomes.

Access to Transportation and Health Care Visits for Medicaid Enrollees With Diabetes.

PURPOSE: Diabetes is a chronic condition that requires frequent health care visits for its management. Individuals without nonemergency medical transportation often miss appointments and do not receive optimal care. This study aims to evaluate the association between Medicaid-provided nonemergency medical transportation and diabetes care visits. METHODS: A retrospective analysis was conducted of demographic and claims data obtained from the Oklahoma Medicaid program. Participants consisted of Medicaid enrollees with diabetes who made at least 1 visit for diabetes care in a year. The sample was predominantly female and white, with an average age of 46.38 years. Two zero-truncated Poisson regression models were estimated to assess the independent effect of transportation use on number of diabetes care visits. FINDINGS: Use of nonemergency medical transportation is a significant predictor of diabetes care visits. Zero-truncated Poisson regression coefficients showed a positive association between the use of transportation and number of visits (0.6563, P < .001). Age, gender, race/ethnicity, area of residence, and presence of additional chronic conditions had independent associations with number of visits. Older enrollees were likely to make more visits than younger enrollees with diabetes (0.02382); controlling for all other factors in the model, rural residents made more visits than urban; women made fewer visits than men (-0.09312; P < .001); and minorities made fewer visits than whites, with pronounced differences for Hispanics and Asians compared to whites. CONCLUSIONS: Findings underscore the importance of ensuring transportation to Medicaid populations with diabetes, particularly in the rural areas where the prevalence of diabetes and complications are higher and the availability of medical resources lower than in the urban areas.

Comparing Access to Laser Capsulotomy Performed by Optometrists and Ophthalmologists in Oklahoma by Calculated Driving Distance and Time.

PURPOSE: To quantify Medicare beneficiary proximity to his or her yttrium-aluminum-garnet (YAG) laser capsulotomy-providing ophthalmologist and optometrist in Oklahoma by calculating driving distances and times. DESIGN: Cross-sectional cohort study using 2014 Oklahoma Medicare 100% and 5% data sets and Google Maps distance and travel time application programming interfaces. PARTICIPANTS: U.S. fee-for-service Medicare beneficiaries and Oklahoma ophthalmologist and optometrist laser capsulotomy providers. METHODS: The 2014 Medicare Provider Utilization and Payment Limited 100% and 5% datasets from the Centers for Medicare and Medicaid (CMS) were obtained to identify the office street addresses of Oklahoma ophthalmologists and optometrists who submitted claims to Medicare for a YAG laser capsulotomy, and the county addresses of the corresponding Medicare beneficiaries who received the laser capsulotomy. The shortest travel distances and travel times between the beneficiary and the laser provider were calculated by using Google Maps distance and travel time application programming interfaces. MAIN OUTCOME MEASURES: Beneficiary driving distances and times to his or her YAG laser capsulotomy-providing Oklahoma ophthalmologist and optometrist. RESULTS: In 2014, 90 (57%) of 157 Oklahoma ophthalmologists and 65 (13%) of 506 Oklahoma optometrists submitted a total of 7521 and 3751 YAG laser capsulotomy claims to Medicare, respectively. By using the Medicare Limited 5% dataset, there was no difference in driving distance between beneficiaries who received a laser capsulotomy from an ophthalmologist (median, 39 miles; interquartile range [IQR], 13-113 miles) compared with an optometrist (median, 46 miles; IQR, 13-125 miles; P = 0.93) or in driving time to an ophthalmologist (median, 47 minutes; IQR, 19-110 minutes) compared with an optometrist (median, 50 minutes; IQR, 17-117 minutes; P = 0.76). CONCLUSIONS: For Medicare beneficiaries, there was no difference in geographic access to YAG laser capsulotomy whether performed by an Oklahoma ophthalmologist or optometrist as determined by calculated driving distances and times.

Cardiovascular Disease Risk Factors and Health Outcomes Among American Indians in Oklahoma: the THRIVE Study.

INTRODUCTION: Limited available data document higher prevalences of cardiovascular disease (CVD) risk factors and health outcomes among American Indians (AIs) compared to other racial/ethnic groups. METHODS: As part of a randomized control trial to improve tribal food and physical activity environments, our tribal-academic partnership surveyed a cross-sectional sample of American Indian adults (n = 513) to assess the prevalence of type 2 diabetes, obesity, hypertension, tobacco use, physical activity, and vegetable and fruit intake. Surveys were collected from April through May 2015. We used logistic regression to examine the association between CVD-related risk factors and health outcomes. RESULTS: The prevalence of CVD-related outcomes was high, ranging from 25% for diabetes to 75% for low vegetable intake. The prevalence of diabetes, obesity, and hypertension tended to be higher among participants with any tobacco use compared to no tobacco use, but findings were not statistically significant. The prevalence of diabetes (prevalence ratio 2.1, 95% CI 1.4-3.2) and obesity (prevalence ratio 1.5, 95% CI 1.2-1.8) was higher among participants with low physical activity levels compared to recommended physical activity levels. CONCLUSIONS: CVD risk factors and health outcomes persist among American Indians even as some risks (e.g., smoking) appear to be stabilizing or even declining in the general US population. Efforts to include American Indians in national health surveys, implement broad reaching environmental and policy interventions, and address the social determinants of health are critical to the elimination of these disparities.

Cancer among American Indians - Identifying Priority Areas in Oklahoma.

BACKGROUND: We describe and compare cancer incidence and mortality among American Indians (AI/ANs) and whites in nine Indian Health Service (IHS) Service Units in Oklahoma. METHODS: Using data from the Oklahoma Central Cancer Registry and the web-based OK2SHARE database, we obtained age-adjusted cancer incidence rates from 1997 to 2012 and cancer mortality rates from 1999 to 2009 for AI/ANs and whites in Oklahoma. We examined differences in primary site, percentage of late stage diagnoses, and trends over time. RESULTS: AI/ANs consistently had higher cancer incidence and mortality compared to whites in Oklahoma. The magnitude of disparity for cancer incidence and mortality varied by IHS Service Unit and by gender. The top three cancer sites were the same for all Service Units. The percentage of late stage diagnosis also varied by region. CONCLUSIONS: We identify priority areas where cancer disparity challenges exist among AI/ANs in Oklahoma.

Impact of a National Cancer Prevention and Treatment Program on the Prevalence of Late-Stage Breast Cancer Diagnoses in Oklahoma.

In 2000, Congress passed the Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) to provide coverage through Medicaid to women who screened positive for breast and cervical cancer. We aimed to determine if late-stage breast cancer prevalence decreased among Oklahoma women after passage of BCCPTA. Data were obtained from the Oklahoma Central Cancer Registry during 2000-2011. We estimated prevalence proportion ratios (PPR) using modified Poisson regression between the proportion of women with late-stage breast cancer and timing of diagnosis related to BCCPTA. Among uninsured women, the probability of being diagnosed with late-stage cancer after enactment of the BCCPTA was 0.80 (95% CI: 0.67, 0.96) times the probability before enactment. This was significant among uninsured women living in metro counties (PPR: 0.74, 95% CI: 0.61, 0.90) but not in non-metro counties (PPR: 1.05, 95% CI: 0.71, 1.56). These findings may be similar to other rural states with large uninsured populations.

Assessment of Body Mass Index, Sugar Sweetened Beverage Intake and Time Spent in Physical Activity of American Indian Children in Oklahoma.

American Indian (AI) children have a combined overweight and obesity prevalence of 53%. Behaviors that contribute to obesity, such as sugar sweetened beverage (SSB) intake and time spent in physical activity (PA), have been poorly explored in this population. The purpose of this study is to report body mass index (BMI), SSB intake, and time spent in PA of 7-to-13-year-old AI children who reside in rural and urban areas in Oklahoma. Cross-sectional survey study. Self-reported SSB intake in the last month, and time spent in PA were collected via questionnaires. Height and weight were professionally measured. The sample included 124 7-to-13-year-old AI children who attended a diabetes prevention summer camp in 2013. BMI percentile, overweight and obesity prevalence, SSB intake, time spent in PA, and number of participants meeting the Physical Activity Guidelines for Americans. Descriptive characteristics for BMI percentile, overweight and obesity, SSB intake, time spent in PA, and meeting PA recommendations were calculated using means, standard deviations, and frequencies. Independent t test and Chi square analyses were used to test for gender differences. Participants were 10.2 ± 1.5 years old and 57% female. Sixty-three percent were overweight or obese. Children consumed 309 ± 309 kcal/day of SSB and spent 4.4 ± 3.8 h per week in moderate-to-vigorous PA. Approximately 32% met the 2008 Physical Activity Guidelines for Americans. No gender differences were observed. The prevalence of overweight and obesity was higher than previously reported in a similar population, and higher than that of US children in the general population. SSB intake and physical activity levels were also found to be higher in this group than in the general population.

Pregnancy intentions and maternal and child health: an analysis of longitudinal data in Oklahoma.

Better understanding of the impact of unintended childbearing on infant and early childhood health is needed for public health practice and policy. Data from the 2004-2008 Oklahoma Pregnancy Risk Assessment Monitoring System survey and The Oklahoma Toddler Survey 2006-2010 were used to examine associations between a four category measure of pregnancy intentions (intended, mistimed <2 years, mistimed ≥2 years, unwanted) and maternal behaviors and child health outcomes up to age two. Propensity score methods were used to control for confounding. Births mistimed by two or more years (OR .58) and unwanted births (OR .33) had significantly lower odds than intended births of having a mother who recognized the pregnancy within the first 8 weeks; they were also about half as likely as intended births to receive early prenatal care, and had significantly higher likelihoods of exposure to cigarette smoke during pregnancy. Breastfeeding was significantly less likely among unwanted births (OR .68); breastfeeding for at least 6 months was significantly less likely among seriously mistimed births (OR .70). We find little association between intention status and early childhood measures. Measured associations of intention status on health behaviors and outcomes were most evident in the prenatal period, limited in the immediate prenatal period, and mostly insignificant by age two. In addition, most of the negative associations between intention status and health outcomes were concentrated among women with births mistimed by two or more years or unwanted births. Surveys should incorporate questions on the extent of mistiming when measuring pregnancy intentions.

Tobacco control and prevention in Oklahoma: best practices in a preemptive state.

For more than a decade, the Oklahoma Tobacco Settlement Endowment Trust and Oklahoma State Department of Health have collaborated to implement best practices in tobacco control through state and community interventions, including legislated and voluntary policy approaches, health communication, cessation programs, and surveillance and evaluation activities. This partnership eliminates duplication and ensures efficient use of public health dollars for a comprehensive tobacco control program based on a systems and social norm change approach. The purpose of this paper is to briefly describe strategies to reduce tobacco use despite a rare policy environment imposed by the presence of near-complete state preemption of tobacco-related law. Key outcome indicators were used to track progress related to state tobacco control and prevention programs. Data sources included cigarette excise tax stamp sales, statewide surveillance systems, Oklahoma Tobacco Helpline registration data, and local policy tracking databases. Data were collected in 2001-2013 and analyzed in 2012 and 2013. Significant declines in cigarette consumption and adult smoking prevalence occurred in 2001-2012, and smoking among high school students fell 45%. Changes were also observed in attitudes and behaviors related to secondhand smoke. Community coalitions promoted adoption of local policies where allowable, with 92 ordinances mirroring state clean indoor air laws and 88 ordinances mirroring state youth access laws. Tobacco-free property policies were adopted by 292 school districts and 309 worksites. Moving forward, tobacco use will be prioritized as an avoidable health hazard in Oklahoma as it is integrated into a wellness approach that also targets obesity reduction.