Recruiting Indigenous Patients Into Clinical Trials: A Circle of Trust.

The Circle of Trust is a new conceptual model that can help investigators and the American Indian/Alaska Natives (AI/AN) community work together to promote inclusion of AI/AN populations in clinical trials to improve health outcomes. Racial/ethnic minority groups remain underrepresented in clinical trials and this creates the need and opportunity for novel approaches. Indigenous populations are particularly underrepresented in clinical trials. Studies show that AI/AN have the lowest representation of race/ethnic groups in the United States. American Indian/Alaska Natives suffer from significant health disparities with higher rates of morbidity and mortality and lower rates for preventative measures and access to health services. A variety of barriers to recruitment of minority patients exist at several levels including the system/institutional, interpersonal, and the individual. The authors, experts in AI/AN health and recruitment of minorities into research, collaborated to modify the currently existing and published "trust triangle" model that focuses on minority recruitment to include participants, researcher, and trusted entity. We advocate for expanding the trust triangle into a circle of trust inclusive of community. The "circle of trust" is a new conceptual model that can help investigators and the AI/AN community work together to promote inclusion of AI/AN populations in clinical trials to improve health outcomes.

Health insurance coverage among American Indians and Alaska Natives in the context of the Affordable Care Act.

Objectives: American Indians and Alaska Natives (AI/AN) have a unique healthcare system uniquely interwoven with the Affordable Care Act (ACA). The aim of this study is to document changes in health insurance among AI/AN adults before and after implementation of the ACA.Design: We used data from the American Community Survey from 2008 to 2016 to examine trends in health insurance. We compared to Non-Hispanic Whites and stratified AI/AN adults with and without Indian Health Service (IHS) coverage. We used multivariate regression to evaluate the probability of health insurance post-ACA and included time period and subgroup interaction terms.Results: Public and private health insurance coverage increased post-ACA by 3.17 and 1.24 percentage points, respectively, but the percent uninsured remained high (37.7% of those with IHS coverage and 19.2% of those without). AI/AN in Medicaid Expansion states had a significantly greater percentage point (pp) increase in public insurance (6.31 pp, 95% CI 5.04-7.59) than AI/AN in non-expansion states (p < 0.001). There was a greater increase in private coverage among AI/AN without IHS compared to AI/AN with IHS coverage (p = 0.002).Conclusions: Despite improvements in healthcare insurance coverage for AI/AN, substantial disparities remain. The improvements appeared to be largely driven by Medicaid Expansion. Without specific considerations for AI/AN, future healthcare reforms could intensify health injustices and inequities they face.

Re-envisioning, Retooling, and Rebuilding Prevention Science Methods to Address Structural and Systemic Racism and Promote Health Equity.

The historic momentum from national conversations on the roots and current impacts of racism in the USA presents an incredible window of opportunity for prevention scientists to revisit how common theories, measurement tools, methodologies, and interventions can be radically re-envisioned, retooled, and rebuilt to dismantle racism and promote equitable health for minoritized communities. Recognizing this opportunity, the NIH-funded Prevention Science and Methodology Group (PSMG) launched a series of presentations focused on the role of Prevention Science to address racism and discrimination guided by a commitment to social justice and health equity. The current manuscript aims to advance the field of Prevention Science by summarizing key issues raised during the series' presentations and proposing concrete research priorities and steps that hold promise for promoting health equity by addressing systemic racism. Being anti-racist is an active practice for all of us, whether we identify as methodologists, interventionists, practitioners, funders, community members, or an intersection of these identities. We implore prevention scientists and methodologists to take on these conversations with us to promote science and practice that offers every life the right to live in a just and equitable world.

Indigenous Cultural Identity of Research Authors Standard: research and reconciliation with Indigenous Peoples in rural health journals.

The Indigenous Cultural Identity of Research Authors Standard (ICIRAS) is based on a gap in research publishing practice where Indigenous peoples' identity is not systematically and rigorously recognised in rural health research publications. There are widespread reforms, in different research areas, to counter the reputation of scientific research as a vehicle of racism and discrimination. Reflecting on these broader movements, the editorial teams of three rural health journals - Rural and Remote Health, the Australian Journal of Rural Health, and the Canadian Journal of Rural Medicine - adopted a policy of 'Nothing about Indigenous Peoples, without Indigenous Peoples'. This meant changing practices so that Indigenous Peoples' identity could be embedded in authorship credentials - such as in the byline. An environmental scan of literature about the inclusion of Indigenous Peoples in research revealed many ways in which editorial boards of journals could improve their process to signal to readers that Indigenous voices are included in rural health research publication governance. Improving the health and wellbeing of Indigenous peoples worldwide requires high-quality research evidence. This quality benchmark needs to explicitly signal the inclusion of Indigenous authors. The ICIRAS is a call to action for research journals and institutions to rigorously improve research governance and leadership to amplify the cultural identity of Indigenous peoples in rural health research.

Integration of the preventive medicine specialty in the rural and Tribal public health workforce.

The majority of the U.S. American Indian and Alaska Native (AI/AN) population live in rural areas, and are thus disproportionately affected by rural health issues. In addition, the AI/AN population has unique health characteristics resulting from a distinct cultural and sociopolitical history. A public health approach to both rural and Tribal health should include the medical specialty of preventive medicine, a unique physician specialty that combines both direct patient care and public health skills. To best prepare preventive medicine physicians for rural and Tribal practice, medical schools could recruit students from rural and Tribal areas and encourage them to pursue the specialty of preventive medicine. Additionally, preventive medicine residency training programs could establish clinical and public health practicum rotations in rural and Tribal areas, and develop curricula that address rural and Tribal health issues. Currently very few preventive medicine residency programs expressly state a mission to train physicians in rural or Tribal settings.

A Prematurity Collaborative Birth Equity Consensus Statement for Mothers and Babies.

INTRODUCTION: In 2016, March of Dimes (MOD) launched its Prematurity Collaborative to engage a broad cross section of national experts to address persistent and widening racial disparities in preterm birth by achieving equity and demonstrated improvements in preterm birth. African-American and Native American women continue to have disproportionate rates of preterm birth and maternal death. As part of the Collaborative, MOD created the Health Equity Workgroup whose task was the creation of a scientific consensus statement articulating core values and a call to action to achieve equity in preterm birth utilizing health equity and social determinants of health frameworks. METHODS: Health Equity Workgroup members engaged in-person and virtually to discuss key determinant contributors and resolutions for disparate maternal and birth outcomes. Workgroup members then drafted the Birth Equity Consensus Statement that contained value statements and a call to action. The birth equity consensus statement was presented at professional conferences to seek broader support. This article highlights the background and context towards arriving at the core values and call to action, which are the two major components of the consensus statement and presents the core values and call to action themselves. RESULTS: The result was the creation of a birth equity consensus statement that highlights risks and protections of social determinants based on the prevailing science, and identifies promising solutions for reducing preterm birth and eliminating racial disparities. CONCLUSION: The birth equity consensus statement provides a mandate, guiding the work of March of Dimes and the broader MCH community, for equity-based research, practice, and policy advocacy at local, state, and federal levels. SIGNIFICANCE: This field report adds to the current knowledge base on racial and ethnic disparities in birth and maternal health outcomes. Research has documented the science behind eliminating health disparities. Scientists and practitioners should continue to explore in practice how the social determinants of birth and maternal health, which manifest historically and contemporarily, can be addressed.

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.

American Indian health policy: historical trends and contemporary issues.

The United States has a trust responsibility to provide services to American Indians and Alaska Native (AI/AN) persons. However, a long-standing history of underfunding of the Indian Health Service (IHS) has led to significant challenges in providing services. Twentieth century laws, including the Snyder Act, Transfer Act, Indian Self-Determination and Education Assistance Act, and Indian Health Care Improvement Act (IHCIA) have had an effect on the way health services are provided. IHCIA was reauthorized as part of the Patient Protection and Affordable Care Act (ACA). Several provisions in ACA allow for potential improvements in access to services for AI/AN populations and are described herein. Although policy developments have been promising, IHS underfunding must be resolved to ensure improved AI/AN health.

Cognitive Impairment and Social Determinants of Health among Indigenous Women.

BACKGROUND AND OBJECTIVES: Cognitive impairment and Alzheimer's disease and related dementias (ADRD) pose significant challenges for Indigenous populations, necessitating urgent research. Limited evidence suggests that high rates of ADRD among Indigenous peoples are associated with social determinants of health (SDOH), such as education, income, health literacy, religion, and social engagement. RESEARCH DESIGN AND METHODS: Collaborating with a Northern Plains tribe, participants were recruited 123 self-identified Indigenous women aged 40 to 70 through a comprehensive recruitment strategy. Employing the SDOH framework, the research assessed cognitive impairment and Alzheimer's disease knowledge, utilizing the Ascertain Dementia 8 and AD knowledge scales (ADK-30). The investigation examined the relationships between selected SDOH variables and cognitive impairment status. RESULTS: More than half of the participants showed signs of cognitive impairment, which correlated with lower income and education levels. Increased knowledge about Alzheimer's disease, particularly in terms of treatment management and its life impact subscales, was associated with lower odds of cognitive impairment. Conversely, higher levels of depressive symptoms and participation in religious activities were linked to increased odds of cognitive impairment. DISCUSSION AND IMPLICATIONS: The findings underscore the importance of culturally grounded tools and SDOH frameworks tailored to Indigenous contexts in addressing ADRD disparities. Future research should integrate historical and cultural factors to advance health equity within Indigenous communities, ultimately mitigating the impact of ADRD and promoting overall well-being.

Chokeberry reduces inflammation in human preadipocytes.

Chokeberry, Aronia melanocarpa, is an indigenous fruit from North America used as food and to prevent chronic disease by Indigenous Peoples. The objective of this study was to test anti-inflammatory effects of anthocyanin on palmitic acid (PA)-induced IL-6 gene expression, IL-6 DNA methylation, and histone (H3) acetylation. Additionally, we examined effects of anthocyanins Cyanidin-3-O-galactoside (C3Gal) and Cyanidin-3-glucoside (C3G) on IL-6 gene expression. Human primary pre-adipocytes were treated with chokeberry juice extract (CBE), C3Gal or C3G in the presence or absence of PA or lipopolysaccharide (LPS). CBE inhibited LPS- and PA-induced IL-6 mRNA expression (p < 0.0001), while C3G and C3Gal had smaller effects. Human IL-6 promoter DNA methylation was increased (p = 0.0256) in CBE treated cells compared to control. Histone H3 acetylations were not affected by CBE or PA treatment. These data indicate that CBE epigenetically reduced PA-induced inflammation by regulating IL-6 DNA methylation without affecting histone modifications in human preadipocyte cells.

Incidence of Stroke in Indigenous Populations of Countries With a Very High Human Development Index: A Systematic Review.

BACKGROUND AND OBJECTIVES: Cardiovascular disease contributes significantly to disease burden among many Indigenous populations. However, data on stroke incidence in Indigenous populations are sparse. We aimed to investigate what is known of stroke incidence in Indigenous populations of countries with a very high Human Development Index (HDI), locating the research in the broader context of Indigenous health. METHODS: We identified population-based stroke incidence studies published between 1990 and 2022 among Indigenous adult populations of developed countries using PubMed, Embase, and Global Health databases, without language restriction. We excluded non-peer-reviewed sources, studies with fewer than 10 Indigenous people, or not covering a 35- to 64-year minimum age range. Two reviewers independently screened titles, abstracts, and full-text articles and extracted data. We assessed quality using "gold standard" criteria for population-based stroke incidence studies, the Newcastle-Ottawa Scale for risk of bias, and CONSIDER criteria for reporting of Indigenous health research. An Indigenous Advisory Board provided oversight for the study. RESULTS: From 13,041 publications screened, 24 studies (19 full-text articles, 5 abstracts) from 7 countries met the inclusion criteria. Age-standardized stroke incidence rate ratios were greater in Aboriginal and Torres Strait Islander Australians (1.7-3.2), American Indians (1.2), Sámi of Sweden/Norway (1.08-2.14), and Singaporean Malay (1.7-1.9), compared with respective non-Indigenous populations. Studies had substantial heterogeneity in design and risk of bias. Attack rates, male-female rate ratios, and time trends are reported where available. Few investigators reported Indigenous stakeholder involvement, with few studies meeting any of the CONSIDER criteria for research among Indigenous populations. DISCUSSION: In countries with a very high HDI, there are notable, albeit varying, disparities in stroke incidence between Indigenous and non-Indigenous populations, although there are gaps in data availability and quality. A greater understanding of stroke incidence is imperative for informing effective societal responses to socioeconomic and health disparities in these populations. Future studies into stroke incidence in Indigenous populations should be designed and conducted with Indigenous oversight and governance to facilitate improved outcomes and capacity building. REGISTRATION INFORMATION: PROSPERO registration: CRD42021242367.

Conceptualizing Indigenous strengths-based health and wellness research using group concept mapping.

BACKGROUND: In recent years public health research has shifted to more strengths or asset-based approaches to health research but there is little understanding of what this concept means to Indigenous researchers. Therefore our purpose was to define an Indigenous strengths-based approach to health and well-being research. METHODS: Using Group Concept Mapping, Indigenous health researchers (N = 27) participated in three-phases. Phase 1: Participants provided 218 unique responses to the focus prompt "Indigenous Strengths-Based Health and Wellness Research…" Redundancies and irrelevant statements were removed using content analysis, resulting in a final set of 94 statements. Phase 2: Participants sorted statements into groupings and named these groupings. Participants rated each statement based on importance using a 4-point scale. Hierarchical cluster analysis was used to create clusters based on how statements were grouped by participants. Phase 3: Two virtual meetings were held to share and invite researchers to collaboratively interpret results. RESULTS: A six-cluster map representing the meaning of Indigenous strengths-based health and wellness research was created. Results of mean rating analysis showed all six clusters were rated on average as moderately important. CONCLUSIONS: The definition of Indigenous strengths-based health research, created through collaboration with leading AI/AN health researchers, centers Indigenous knowledges and cultures while shifting the research narrative from one of illness to one of flourishing and relationality. This framework offers actionable steps to researchers, public health practitioners, funders, and institutions to promote relational, strengths-based research that has the potential to promote Indigenous health and wellness at individual, family, community, and population levels.

American Indian/Alaska Native cancer policy: systemic approaches to reducing cancer disparities.

Members of American Indian and Alaska Native (AI/AN) tribes have a unique political status in the United States in terms of citizenship, and that political status determines eligibility for certain unique healthcare services. The AI/AN population has a legal right to healthcare services based on treaties, court decisions, acts of Congress, Executive Orders, and other legal bases. Although the AI/AN population has a right to healthcare services, the Indian Health Service (the federal agency responsible for providing healthcare to AI/ANs) is severely underfunded, limiting access to services (including cancer care). In order to overcome distinct cancer health disparities, policy changes will be needed. This paper reviews the historical pattern of AI/AN healthcare and the challenges of the complex care needed from prevention through end-of-life care for cancer.

Uranium Exposure in American Indian Communities: Health, Policy, and the Way Forward.

BACKGROUND: Uranium contamination of drinking-water sources on American Indian (AI) reservations in the United States is a largely ignored and underfunded public health crisis. With an estimated 40% of the headwaters in the western U.S. watershed, home to many AI reservation communities, being contaminated with untreated mine waste, the potential health effects have largely been unexplored. With AI populations already facing continued and progressive economic and social marginalization, higher prevalence of chronic disease, and systemic discrimination, associations between various toxicant exposures, including uranium, and various chronic conditions, need further examination. OBJECTIVES: Uranium's health effects, in addition to considerations for uranium drinking-water testing, reporting, and mitigation in reference to AI communities through the lens of water quality, is reviewed. DISCUSSION: A series of environmental health policy recommendations are described with the intent to proactively improve responsiveness to the water quality crisis in AI reservation communities in the United States specific to uranium. There is a serious and immediate need for better coordination of uranium-related drinking-water testing and reporting on reservations in the United States that will better support and guide best practices for uranium mitigation efforts. https://doi.org/10.1289/EHP7537.

Stress and Cardiometabolic Disease Risk for Indigenous Populations throughout the Lifespan.

BACKGROUND: Indigenous people experience the greatest cardiometabolic disease disparity in the Unites States, yet high cardiometabolic disease risk factors do not fully explain the extent of the cardiometabolic disease disparity for Indigenous people. Stress, trauma, and racism occur at high rates within Indigenous communities and have not been well explored as significant contributors to cardiometabolic disease disparities despite emerging literature, and therefore will be described here. METHODS: This descriptive study explores the relationship between cardiometabolic disease risks and Indigenous-specific stressors (e.g., early childhood stress and trauma, adulthood stress and trauma, and historical and intergenerational trauma) using current literature. Indigenous-specific protective factors against cardiometabolic disease are also reviewed. RESULTS: Increasing research indicates that there is a relationship between Indigenous-specific stressful and traumatic life experiences and increased cardiometabolic disease risk. Mental health and psychophysiology play an important role in this relationship. Effective interventions to reduce cardiometabolic disease risk in Indigenous communities focus on ameliorating the negative effects of these stressors through the use of culturally specific health behaviors and activities. CONCLUSIONS: There is increasing evidence that cultural connection and enculturation are protective factors for cardiometabolic disease, and may be galvanized through Indigenous-led training, research, and policy change.

The Incidence of Stroke in Indigenous Populations of Countries With a Very High Human Development Index: A Systematic Review Protocol.

Background and Aims: Despite known Indigenous health and socioeconomic disadvantage in countries with a Very High Human Development Index, data on the incidence of stroke in these populations are sparse. With oversight from an Indigenous Advisory Board, we will undertake a systematic review of the incidence of stroke in Indigenous populations of developed countries or regions, with comparisons between Indigenous and non-Indigenous populations of the same region, though not between different Indigenous populations. Methods: Using PubMed, OVID-EMBASE, and Global Health databases, we will examine population-based incidence studies of stroke in Indigenous adult populations of developed countries published 1990-current, without language restriction. Non-peer-reviewed sources, studies including <10 Indigenous People, or with insufficient data to determine incidence, will be excluded. Two reviewers will independently validate the search strategies, screen titles and abstracts, and record reasons for rejection. Relevant articles will undergo full-text screening, with standard data extracted for all studies included. Quality assessment will include Sudlow and Warlow's criteria for population-based stroke incidence studies, the Newcastle-Ottawa Scale for risk of bias, and the CONSIDER checklist for Indigenous research. Results: Primary outcomes include crude, age-specific and/or age-standardized incidence of stroke. Secondary outcomes include overall stroke rates, incidence rate ratio and case-fatality. Results will be synthesized in figures and tables, describing data sources, populations, methodology, and findings. Within-population meta-analysis will be performed if, and where, methodologically sound and comparable studies allow this. Conclusion: We will undertake the first systematic review assessing disparities in stroke incidence in Indigenous populations of developed countries. Data outputs will be disseminated to relevant Indigenous stakeholders to inform public health and policy research.