Actual causes of death in Alaska.

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

Lack of in-home piped water and reported consumption of sugar-sweetened beverages among adults in rural Alaska.

OBJECTIVE: To assess whether a community water service is associated with the frequency of sugar-sweetened beverages (SSB) consumption, obesity, or perceived health status in rural Alaska. DESIGN: We examined the cross-sectional associations between community water access and frequency of SSB consumption, body mass index categories, and perceived health status using data from the 2013 and 2015 Alaska Behavioral Risk Factor Surveillance System (BRFSS). Participants were categorized by zip code to 'in-home piped water service' or 'no in-home piped water service' based on water utility data. We evaluated the univariable and multivariable (adjusting for age, household income and education) associations between water service and outcomes using log-linear survey-weighted generalized linear models. SETTING: Rural Alaska, USA. SUBJECTS: Eight hundred and eighty-seven adults, aged 25 years and older. RESULTS: In unadjusted models, participants without in-home water reported consuming SSB more often than participants with in-home water (1·46, 95 % CI: 1·06, 2·00). After adjustment for potential confounders, the effect decreased but remained borderline significant (1·29, 95 % CI: 1·00, 1·67). Obesity was not significantly associated with water service but self-reported poor health was higher in those communities without in-home water (1·63, 95 % CI: 1·05, 2·54). CONCLUSIONS: Not having access to in-home piped water could affect behaviours surrounding SSB consumption and general perception of health in rural Alaska.

An Innovative Tribal-State Partnership: The Development of the Healthy Alaskans 2020 Statewide Health Improvement Plan.

This article details the development of Healthy Alaskans 2020, Alaska's statewide health improvement plan. Healthy Alaskans 2020 is a framework that supports collaborative efforts among many agencies and communities working toward the common goals of improving health and ensuring health equity for all Alaskans. The initiative was created through a unique tribal-state partnership between the Alaska Native Tribal Health Consortium and the Alaska Department of Health and Social Services. Through an iterative process using the best available epidemiologic data and extensive community input, Alaskan's health priorities were identified, with 25 leading health indicators and accompanying targets to be met by 2020. Two indicator scorecards, one for all Alaskans and one specifically for Alaska Native people, are updated annually and used for continual monitoring. The collaborative and iterative nature of Healthy Alaskans provides a model for others interested in creating multisector health improvement initiatives that align goals across systems and partners.

The Real Cost: Alaska's innovative media campaign to raise awareness about the direct and indirect costs of smoking to society.

Smoking incurs heavy financial costs for direct medical expenditures and lost productivity related to premature death. The Alaska Tobacco Prevention and Control Program designed a media campaign called 'The Real Cost' to raise awareness of the economic cost of smoking to all Alaskans, regardless of their smoking status. The campaign presented this information through television and radio ads between December 2012 and March 2013. The first ad, 'Dream Scene', focused on overall cost of smoking to Alaska. The second ad, 'Oil Change', focused on lost productivity. We conducted three cross-sectional telephone surveys, one prior to the campaign and one after each ad was run to assess changes in beliefs associated with the main campaign messages. At Survey 2, we observed increased adjusted odds of agreement with the main campaign message, 'I am affected financially by other people's smoking' (adjusted odds ratio = 4.5, 95% confidence interval = 3.0-6.7). At Survey 3, we observed elevated adjusted odds of agreement for beliefs related to all campaign messages. This campaign was successful in raising knowledge and awareness of the cost of smoking on a societal level among adult, nonsmoking residents of Alaska.

Smoking cessation patterns by socioeconomic status in Alaska.

The ongoing disparity in smoking prevalence across levels of socioeconomic status (SES) is a significant concern in the tobacco control field, and surveillance of cessation-related activity is key to understanding progress. Historically, lower SES smokers have had much lower quit ratios but this measure can be insensitive to recent quit-related behavior. It is therefore important to examine recent quit-related behavior to assess progress toward addressing this disparity, especially in states with tobacco control programs that focus on this priority population. We compared recent quit attempts and successes among non-Native lower SES Alaska smokers to those of higher SES using data from the 2012-2013 Alaska Behavioral Risk Factor Surveillance System (BRFSS). We assessed quit ratios, one-year and five-year quit rates, and six-month abstinence between the two groups. Cessation-related measures restricted to those who smoked in the previous one year did not significantly vary by SES. However, five year quit rates were significantly lower for persons of lower SES vs. higher SES (14% vs. 32% respectively, p < .001). Results were consistent after adjustment for age, sex, and other factors. Results showed that in the previous year, smokers of lower SES in Alaska were trying to quit and succeeding at similar rates as their higher SES counterparts. However, the equivalent pattern of quit success was not reflected in the five-year time frame. Tobacco control programs should monitor cessation trends using both recent and longer-term time frames for this population. More research is needed on reasons for fewer long-term quits among lower SES smokers.

Estimating the Prevalence of Childhood Obesity in Alaska Using Partial, Nonrandom Measurement Data.

Although monitoring childhood obesity prevalence is critical for state public health programs to assess trends and the effectiveness of interventions, few states have comprehensive body mass index measurement systems in place. In some states, however, assorted school districts collect measurements on student height and weight as part of annual health screenings. To estimate childhood obesity prevalence in Alaska, we created a logistic regression model using such annual measurements along with public data on demographics and socioeconomic status. Our mixed-effects model-generated prevalence estimates validated well against weighted estimates, with 95% confidence intervals overlapping between methodologies among 7 of 8 participating school districts. Our methodology accounts for variation in school-level and student-level demographic factors across the state, and the approach we describe can be applied by other states that have existing nonrandom student measurement data to estimate childhood obesity prevalence.

Effectiveness of a tobacco quitline in an indigenous population: a comparison between Alaska Native people and other first-time quitline callers who set a quit date.

OBJECTIVES: To conduct a descriptive, comparative study of the acceptability and effectiveness of a tobacco cessation quitline (QL) among Alaska Native people and non-Alaska Native people. STUDY DESIGN: From January 2006 to January 2007, we conducted telephone surveys of first-time Alaska QL callers who set a quit date. We attempted to reach them by phone about 3 months after their call to the QL. METHODS: Analyses compared 7-day point prevalence quit rates, satisfaction measures, experiences and general perceptions of QLs by Alaska Native and non-Alaska Native callers. RESULTS: We surveyed 39.8% (n = 772) of the 1,941 adult tobacco users we attempted to contact. The 7-day point prevalence quit rate among Alaska Native survey participants at the 3-month follow-up was 22.2% (CI: 14.8% - 32.0%), compared to 40.7% (CI: 36.7% - 44.9%) for non-Alaska Native survey participants. Eighty-three percent (CI: 74.6% - 89.3%) were somewhat/very satisfied overall with the QL program compared to 90.3% (CI: 87.6% - 92.4%) for non-Alaska Native participants. CONCLUSIONS: Although the QL was less effective for Alaska Native callers than other QL callers, Alaska Native peoples' quit rates and satisfaction were still quite good. Despite this, more effort should be made to address specific Alaska Native values and social and cultural barriers to quitting tobacco.

Correlates of Alaska Native fatal and nonfatal suicidal behaviors 1990-2001.

Factors correlated with suicidal behavior in a predominately Alaska Native region of Alaska are described, and the correlates relating to fatal and nonfatal suicide behaviors in this indigenous population are distinguished. Suicide data from the region (1990-2001) were aggregated and compared to 2000 U.S. Census Data using chi-squared tests. Multivariable logistic regression was used to identify predictors of suicide behaviors. Suicidal behaviors were significantly more common among single, unemployed Alaska Natives who had not completed high school. In multivariable analysis, male sex, age > or = 25 years, firearms, and substance abuse history were each associated with suicide death.

Hepatitis A prevalence among injection drug users.

OBJECTIVE: The purpose of this study was to develop a descriptive model of the association between injection drug use and hepatitis A (HAV) in a sample of injection drug users (IDUs). DESIGN: From May 1997 to July 1999, 493 subjects were administered the NIDA Risk Behavior Assessment (RBA). Participants had blood drawn; sera were tested for antibodies to HAV, hepatitis B core (HBcAB), and hepatitis C. The principal method of analysis was logistic regression. SETTING: The study took place in a community-based field station in Anchorage, Alaska. PARTICIPANTS: Eligibility was determined using the following criteria: a) age greater than 17 years, b) possession of picture identification, c) positive urinalysis for cocaine metabolites, morphine, and/or amphetamines using the ONTRAK system (Roche Diagnostics), and d) injection drug use in the last six months as confirmed by presentation of track marks. MAIN OUTCOME MEASURE: Presence of antibodies to HAV infection. RESULTS: The prevalence of total HAV antibody in our sample was 33% (161/493). The final multivariate logistic model, using positive HAV serostatus as the outcome, included positive HBcAB serostatus (OR = 3.43; 95% CI, 2.22-5.30), less than high school education (vs. high school or greater education) (OR = 2.05; 95% CI, 1.33-3.17), age (OR = 1.06 (each year); 95% CI, 1.03-1.09), number of days injected heroin in the last 30 days (OR = 1.05 (each day), 95% CI, 1.01-1.08), and race (White vs. all other race/ethnicities) (OR = 0.49; 95% CI, 0.32-0.75). CONCLUSIONS: A model including both demographic and drug use variables best describes HAV prevalence in this sample. Findings suggest that IDUs are targets for interventions focusing on hepatitis vaccinations and hygiene practices. Further research is needed to understand the association of HAV with hepatitis B infection.

Technology and managed care: patient benefits of telemedicine in a rural health care network.

Rural health providers have looked to telemedicine as a technology to reduce costs. However, virtual access to physicians and specialists may alter patients' demand for face-to-face physician access. We develop a model of service demand under managed care, and apply the model to a telemedicine application in rural Alaska. Provider-imposed delays and patient costs were highly significant predictors of patient contingent choices in a survey of ENT clinic patients. The results suggest that telemedicine increased estimated patient benefits by about $40 per visit, and reduced patients' loss from rationing of access to physicians by about 20%.

"Here's what I'd do...": condom promotion strategies proposed by high-risk women in Anchorage, Alaska.

Women drug users are at significant risk of sexually transmitted HIV; however, interventions aimed at increasing condom use by this population have been relatively ineffective. The authors conducted a series of focus groups with 17 current and former drug-using women to identify (a) reasons for using versus not using condoms, (b) intervention strategies they believed would be most effective at increasing condom use, and (c) previous ineffective intervention strategies. Risk of HIV, sexually transmitted diseases, and pregnancy was the main reason given for using condoms. Many factors were identified that limited condom use, including lack of availability, substance use, and cost. Participants enthusiastically endorsed condom availability and AIDS awareness interventions, and suggested that no intervention was a waste of money. The authors discuss the limitations of the suggested interventions and recommend additional research to evaluate the efficacy of these strategies.

A condom skill scale: assessing condom skills among female drug users.

Use of latex condoms is a primary form of sexual risk reduction, and consequently many intervention programs have focused efforts on increasing condom use among high-risk populations. Use alone, however, will not fully protect the individual if condoms are not used correctly. The objective of this study was to describe the development and properties of a scale measuring demonstrated condom use skill using a sample of 261 drug-using women. Guttman's coefficient of reproducibility and Jackson's Plus Percentage Ratio (PPR) were used to determine the scalability of the Condom Skill Scale (CSS). Analysis of scale scores revealed high levels of condom skill among the population, although there was reduced performance for three items. Preliminary analysis suggests that the CSS is a potentially valid and reliable instrument, and may have application as a tool assessing condom skill level.

Needle exchange and injection drug use frequency: a randomized clinical trial.

Despite a lack of evidence that needle exchange programs (NEPs) cause an increase in injection drug use, there are still concerns over fostering increased injection behavior with NEPs. The design was a randomized controlled trial conducted from May 1997 to June 2000 comparing injection drug users (IDUs) who are randomly assigned to have access to an NEP versus training in how to purchase needles and syringes (NS) at pharmacies. Of 653 IDUs recruited into the study, 600 were randomized: 426 were followed-up at 6 months, and 369 were followed-up at 12 months. Four hundred ninety were followed up at least once. There was no difference in the number of injections over time between the NEP and the Pharmacy Sales arms of the study or in the percentage of positive urine test results over time between the NEP and the Pharmacy Sales arms of the study for morphine and amphetamine. The decrease in the presence of cocaine was marginally greater between the arms of the study. The results do not support the hypothesis of NEPs causing an increase in injection drug use. This clinical trial provides the strongest evidence to date that needle exchanges do not produce this negative effect.

Perceptions of power equality among drug-using women.

This study examined the associations between perceptions of the power equality in a current sexual relationship and each of several alternative indicators of power in a sample of drug-using women. Using targeted sampling, 262 women were recruited from the streets of Anchorage, Alaska. A battery of face-to-face questionnaires was administered to adult women who gave evidence of recent drug use (track marks or positive urinalysis) and had been recently sexually active. Perceived power equality was associated with physical, verbal, and sexual abuse, self-efficacy, sexual communication, and income for main partners, and the trade of sex and traditionalism of her views on home and family for casual partners. These findings suggest that power is a complex, multifaceted construct, and that type of relationship must be considered when trying to understand the meaning of power within drug-using women's lives. Implications for risk behavior interventions are discussed.

Social isolation and domestic violence among female drug users.

The objective of this study was to examine the association between social isolation, domestic violence, and substance dependence among street-recruited female drug users. Hierarchical logistic regression was used to assess the independent contribution of social isolation and substance dependence to the likelihood that women will experience physical abuse. One hundred women (38.2%. N = 262) reported at least one incident of physical violence perpetrated by her most-recent sexual partner. Controlling for substance dependence and relationship status (the only significantly associated demographic variable), women reporting indicators of social isolation were more likely to have been physically abused by their most-recent sexual partners than nonisolated women. Substance dependence was not related significantly to domestic violence. Providers who have contact with female drug users should be aware of the high domestic violence rates and work to counterbalance the isolation these women may experience.