A Framework for Culturally Relevant Online Learning: Lessons from Alaska's Tribal Health Workers.

Culturally relevant health promotion is an opportunity to reduce health inequities in diseases with modifiable risks, such as cancer. Alaska Native people bear a disproportionate cancer burden, and Alaska's rural tribal health workers consequently requested cancer education accessible online. In response, the Alaska Native Tribal Health Consortium cancer education team sought to create a framework for culturally relevant online learning to inform the creation of distance-delivered cancer education. Guided by the principles of community-based participatory action research and grounded in empowerment theory, the project team conducted a focus group with 10 Alaska Native education experts, 12 culturally diverse key informant interviews, a key stakeholder survey of 62 Alaska Native tribal health workers and their instructors/supervisors, and a literature review on distance-delivered education with Alaska Native or American Indian people. Qualitative findings were analyzed in Atlas.ti, with common themes presented in this article as a framework for culturally relevant online education. This proposed framework includes four principles: collaborative development, interactive content delivery, contextualizing learning, and creating connection. As an Alaskan tribal health worker shared "we're all in this together. All about conversations, relationships. Always learn from you/with you, together what we know and understand from the center of our experience, our ways of knowing, being, caring." The proposed framework has been applied to support cancer education and promote cancer control with Alaska Native people and has motivated health behavior change to reduce cancer risk. This framework may be adaptable to other populations to guide effective and culturally relevant online interventions.

Culturally-Relevant Online Cancer Education Modules Empower Alaska's Community Health Aides/Practitioners to Disseminate Cancer Information and Reduce Cancer Risk.

To address a desire for timely, medically accurate cancer education in rural Alaska, ten culturally relevant online learning modules were developed with, and for, Alaska's Community Health Aides/Practitioners (CHA/Ps). The project was guided by the framework of Community-Based Participatory Action Research, honored Indigenous Ways of Knowing, and was informed by Empowerment Theory. A total of 428 end-of-module evaluation surveys were completed by 89 unique Alaska CHA/Ps between January and December 2016. CHA/Ps shared that as a result of completing the modules, they were empowered to share cancer information with their patients, families, friends, and communities, as well as engage in cancer risk reduction behaviors such as eating healthier, getting cancer screenings, exercising more, and quitting tobacco. CHA/Ps also reported the modules were informative and respectful of their diverse cultures. These results from end-of-module evaluation surveys suggest that the collaboratively developed, culturally relevant, online cancer education modules have empowered CHA/Ps to reduce cancer risk and disseminate cancer information. "brought me to tears couple of times, and I think it will help in destroying the silence that surrounds cancer".

Co-Creating a Culturally Responsive Distance Education Cancer Course with, and for, Alaska's Community Health Workers: Motivations from a Survey of Key Stakeholders.

To gain input on a proposed culturally responsive, distance-delivered cancer education course informed by empowerment theory and adult-learning principles, Alaska's Community Health Aides/Practitioners (CHA/Ps) and CHA/P leadership were invited to take an online survey in February 2015. The proposed course will be developed as part of the "Distance Education to Engage Alaskan Community Health Aides in Cancer Control" project. The results of the survey demonstrate that respondents are both interested in taking the proposed class and engaging in course development. The results also indicate that respondents have the technological comfort and capacity to be engaged in online learning and have primarily positive experiences and perceptions of distance education. This survey is the beginning of the interactive development of the online cancer education course and part of a continuing endeavor to promote wellness with, and for, Alaska's people by empowering Alaska's CHA/Ps and inspiring positive behavioral change to both prevent cancer and support those who feel its burdens.

Engaging Elements of Cancer-Related Digital Stories in Alaska.

The tradition of storytelling is an integral part of Alaska Native cultures that continues to be a way of passing on knowledge. Using a story-based approach to share cancer education is grounded in Alaska Native traditions and people's experiences and has the potential to positively impact cancer knowledge, understandings, and wellness choices. Community health workers (CHWs) in Alaska created a personal digital story as part of a 5-day, in-person cancer education course. To identify engaging elements of digital stories among Alaska Native people, one focus group was held in each of three different Alaska communities with a total of 29 adult participants. After viewing CHWs' digital stories created during CHW cancer education courses, focus group participants commented verbally and in writing about cultural relevance, engaging elements, information learned, and intent to change health behavior. Digital stories were described by Alaska focus group participants as being culturally respectful, informational, inspiring, and motivational. Viewers shared that they liked digital stories because they were short (only 2-3 min); nondirective and not preachy; emotional, told as a personal story and not just facts and figures; and relevant, using photos that showed Alaskan places and people.

Cancer disparities among Alaska native people, 1970-2011.

INTRODUCTION: Cancer is the leading cause of death among Alaska Native people. The objective of this study was to examine cancer incidence data for 2007-2011, age-specific rates for a 15-year period, incidence trends for 1970-2011, and mortality trends for 1990-2011. METHODS: US data were from the Surveillance, Epidemiology, and End Results (SEER) Program SEER*Stat database and from the SEER Alaska Native Tumor Registry. Age-adjusted cancer incidence rates among Alaska Native people and US whites were compared using rate ratios. Trend analyses were performed using the Joinpoint Regression Program. Mortality data were from National Center for Health Statistics. RESULTS: During 2007-2011 the cancer incidence rate among Alaska Native women was 16% higher than the rate among US white women and was similar among Alaska Native men and US white men. Incidence rates among Alaska Native people exceeded rates among US whites for nasopharyngeal, stomach, colorectal, lung, and kidney cancer. A downward trend in colorectal cancer incidence among Alaska Native people occurred from 1999 to 2011. Significant declines in rates were not observed for other frequently diagnosed cancers or for all sites combined. Cancer mortality rates among Alaska Native people during 2 periods, 1990-2000 and 2001-2011, did not decline. Cancer mortality rates among Alaska Native people exceeded rates among US whites for all cancers combined; for cancers of the lung, stomach, pancreas, kidney, and cervix; and for colorectal cancer. CONCLUSION: Increases in colorectal screening among Alaska Native people may be responsible for current declines in colorectal cancer incidence; however; improvements in treatment of colon and rectal cancers may also be contributing factors.

Qualitative evaluation of a colorectal cancer education CD-ROM for Community Health Aides/practitioners in Alaska.

Colorectal cancer (CRC) is an important contributor to the cancer burden among Alaska Native people. CRC is the leading incident cancer and the second leading cause of cancer mortality among Alaska Native people. Completing recommended CRC screening procedures has the potential to reduce both CRC incidence and mortality. "Taking Action Colorectal Health," a multidimensional audiovisual, interactive CD-ROM, incorporates adult education learning principles to provide Alaska's Community Health Aides/Practitioners with timely, medically accurate, and culturally relevant CRC place-based education. Providing this resource on CD-ROM empowers learning within communities and places where people live or choose to learn. The dynamic process of developing, implementing, and evaluating this CRC CD-ROM was informed by a sociocultural approach to share health messages. Within this approach, cultural values, beliefs, and behaviors are affirmed as a place of wisdom and resilience and built upon to provide context and meaning for health messaging. Alaska Native values that honor family, relationships, the land, storytelling, and humor were included in CD-ROM content. Between January and May 2012, 20 interviews were conducted with individuals who had used the CD-ROM. Four categorical themes emerged from analysis of interview transcripts: likeability, utilization, helpfulness, and behavior change. As a result of self-paced learning through stories, movies, and interactive games, respondents reported healthy behavior changes they were making for themselves, with their families and in their patient care practices. This CD-ROM is a culturally based practical course that increased knowledge and activities around colorectal cancer screening by Community Health Aides/Practitioners in Alaska.

Evaluating arts-based cancer education using an internet survey among Alaska community health workers.

Cancer, considered a rare disease among Alaska Native people as recently as the 1950s, surpassed heart disease in the 1990s to become the leading cause of mortality. In response to Alaska's village-based Community Health Workers' (CHWs) desire to learn more about cancer for themselves and the people in their communities, cancer education that incorporated the expressive arts of moving, drawing, and sculpting was developed, implemented, and evaluated. Arts-based education integrates the dynamic wisdom and experiences of Alaska Native people and western medical knowledge to share cancer information in a culturally respectful way. Between May 2009 and March 2013, 12 5-day courses that included arts activities to support cancer information were provided for 118 CHWs in Anchorage, AK, USA. A post-course internet survey was conducted in April 2013, to learn how arts-based cancer education affected participants' knowledge, attitudes, and behaviors. Surveys were completed by 54 of the 96 course participants; 22 course participants were lost to follow-up. As a result of integrating the arts with cancer education, respondents reported an increase in their cancer knowledge and comfort with talking about cancer. Additionally, 82 % (44) of respondents described feeling differently about cancer. By integrating the arts with cancer information, participants reported healthy behavior changes for themselves (76 %), with their families (70 %), and in their work (72 %). The expressive arts of moving, drawing, and sculpting provided a creative pathway for diverse adult learners in Alaska to increase their cancer knowledge, comfort with talking about cancer, and wellness behaviors.

Alaska Native smokers and smokeless tobacco users with slower CYP2A6 activity have lower tobacco consumption, lower tobacco-specific nitrosamine exposure and lower tobacco-specific nitrosamine bioactivation.

Nicotine, the psychoactive ingredient in tobacco, is metabolically inactivated by CYP2A6 to cotinine. CYP2A6 also activates procarcinogenic tobacco-specific nitrosamines (TSNA). Genetic variation in CYP2A6 is known to alter smoking quantity and lung cancer risk in heavy smokers. Our objective was to investigate how CYP2A6 activity influences tobacco consumption and procarcinogen levels in light smokers and smokeless tobacco users. Cigarette smokers (n = 141), commercial smokeless tobacco users (n = 73) and iqmik users (n = 20) were recruited in a cross-sectional study of Alaska Native people. The participants' CYP2A6 activity was measured by both endophenotype and genotype, and their tobacco and procarcinogen exposure biomarker levels were also measured. Smokers, smokeless tobacco users and iqmik users with lower CYP2A6 activity had lower urinary total nicotine equivalents (TNE) and (methylnitrosamino)-1-(3)pyridyl-1-butanol (NNAL) levels (a biomarker of TSNA exposure). Levels of N-nitrosonornicotine (NNN), a TSNA metabolically bioactivated by CYP2A6, were higher in smokers with lower CYP2A6 activities. Light smokers and smokeless tobacco users with lower CYP2A6 activity reduce their tobacco consumption in ways (e.g. inhaling less deeply) that are not reflected by self-report indicators. Tobacco users with lower CYP2A6 activity are exposed to lower procarcinogen levels (lower NNAL levels) and have lower procarcinogen bioactivation (as indicated by the higher urinary NNN levels suggesting reduced clearance), which is consistent with a lower risk of developing smoking-related cancers. This study demonstrates the importance of CYP2A6 in the regulation of tobacco consumption behaviors, procarcinogen exposure and metabolism in both light smokers and smokeless tobacco users.

Tobacco use among southwestern Alaska Native people.

INTRODUCTION: We examined the characteristics, attitudes, beliefs, and exposure to tobacco products in a cohort of rural dwelling Alaska Native (AN) people. METHODS: We conducted a study of 400 of AN adult tobacco users and nonusers living in Southwestern Alaska. Questionnaires covered variables such as demographics, tobacco-use history, current tobacco use and dependence scales, general health status, attitudes and beliefs about tobacco, and quitting history. RESULTS: The study population smoked 7.8 cigarettes per day compared with 16.8 on average for the U.S. population: a significant proportion of the population engaged in dual use of cigarettes and smokeless tobacco products. Over one third (40.9%), first tried tobacco at age 11 or younger. The mean measures of tobacco addiction (e.g., Fagerstrom Test for Nicotine Dependence, Severson Scale of Smokeless Tobacco Dependence) scores were lower compared with other U.S. populations. CONCLUSIONS: Very high tobacco-use prevalence, dual product use, and early tobacco use are observed in Southwestern AN people. Unexpectedly these did not appear to be correlated with heavier individual tobacco use or higher levels of addiction in this population.

CYP2A6 and CYP2B6 genetic variation and its association with nicotine metabolism in South Western Alaska Native people.

OBJECTIVES: Alaska Native (AN) people have a high prevalence of tobacco use and associated morbidity and mortality when compared with the general USA population. Variations in the CYP2A6 and CYP2B6 genes, encoding enzymes responsible for nicotine metabolic inactivation and procarcinogen activation, have not been characterized in AN and may contribute toward the increased risk. METHODS: AN people (n=400) residing in the Bristol Bay region of South Western Alaska were recruited for a cross-sectional study on tobacco use. They were genotyped for CYP2A6*1X2A, *1X2B, *1B, *2, *4, *7, *8, *9, *10, *12, *17, *35 and CYP2B6*4, *6, *9 and provided plasma and urine samples for the measurement of nicotine and metabolites. RESULTS: CYP2A6 and CYP2B6 variant frequencies among the AN Yupik people (n=361) were significantly different from those in other ethnicities. Nicotine metabolism [as measured by the plasma and urinary ratio of metabolites trans-3'-hydroxycotinine to cotinine (3HC/COT)] was significantly associated with CYP2A6 (P<0.001), but not CYP2B6 genotype (P=0.95) when controlling for known covariates. It was noteworthy that the plasma 3HC/COT ratios were high in the entire Yupik people, and among the Yupik CYP2A6 wild-type participants, they were substantially higher than those in previously characterized racial/ethnic groups (P<0.001 vs. Caucasians and African Americans). CONCLUSION: Yupik AN people have a unique CYP2A6 genetic profile that associated strongly with in-vivo nicotine metabolism. More rapid CYP2A6-mediated nicotine and nitrosamine metabolism in the Yupik people may modulate the risk of tobacco-related diseases.

The Alaska Education and Research Towards Health (EARTH) Study: cancer risk factors.

The Alaska Education and Research Towards Health (EARTH) Study assessed cancer risk among 3,821 Alaska Native people (AN). We present the prevalence of selected cancer risk factors and comparison with Healthy People 2010 goals. Participants completed extensive computer-assisted self-administered questionnaires on diet, physical activity, tobacco and alcohol use, cancer screening, family history of cancer, and environmental exposures. Measurement data were collected on blood pressure, height, weight, waist/hip circumference, fasting serum lipids, and glucose. Cancer risk factors are high for the Alaska EARTH study population. For all risk factors studied except for vegetable consumption, Alaska EARTH Study participants did not meet Healthy People 2010 goals. This study is unique in providing questionnaire and measurement data of cancer risk factors on a larger study sample than any previous study among AN living in Alaska. Data show that the prevalence of most cancer risk factors exceeded national recommendations. Given the disease disparities that exist for the AN population, these data provide important baseline data that can be used to target health interventions and reduce health disparities.

Occupational and environmental exposures among Alaska Native and American Indian people living in Alaska and the Southwest United States.

Most occupational and environmental research describes associations between specific occupational and environmental hazards and health outcomes, with little information available on population-level exposure, especially among unique subpopulations. The authors describe the prevalence of self-reported lifetime exposure to nine occupational and environmental hazards among 11,326 American Indian and Alaska Native (AI/AN) adults enrolled in the Education and Research Towards Health (EARTH) Study in the Southwest U.S. and Alaska. The top three hazards experienced by AI/AN people in Alaska were petroleum products, military chemicals, and asbestos. The top three hazards experienced by AI/AN living in the Southwest U.S. were pesticides, petroleum, and welding/silversmithing. The study described here found that male sex, lower educational attainment, AI/AN language use, and living in the Southwest U.S. (vs. Alaska) were all associated with an increased likelihood of hazard exposure. The authors' study provides baseline data to facilitate future exposure-response analyses. Future studies should measure dose and duration as well as environmental hazards that occur in community settings.

Strategies for successful retention of Alaska Native and American Indian study participants.

This paper reports the strategies used to track and follow 3,828 Alaska Native and American Indian study participants in the city of Anchorage and more rural areas of Alaska and provides characteristics of respondents and non-respondents. Over 88% were successfully followed-up, with 49% of respondents completed in three or fewer attempts. Follow-up completion rates were significantly higher for women, those living in a rural area, over age 55, married, employed, having a higher household income, and at current residence for more than five years. Follow-up of large numbers of Alaska Native and American Indian people living in geographically diverse areas is feasible, although challenging. Successful strategies to avoid attrition include using telephones as the primary method of contact; using a computerized contact relationship management system to track efforts and manage data; obtaining contact information from participant contact networks, medical records, and community networks; using local village interviewers to contact participants without telephone service; and mailing paper questionnaires to participants who are incarcerated or use social services.

Tobacco use among Alaska Native people in the EARTH study.

INTRODUCTION: While aggregate rates of tobacco use for Alaska Native (AN) and American Indian people are high, use rates vary among populations and factors associated with use are not fully understood. For AN people living in three regions of Alaska, we present prevalence of tobacco use as well as factors associated with use. METHODS: Using data from 3,828 participant questionnaires, associations with tobacco use are examined with chi-square tests and multivariate logistic regression. Covariates investigated include demographic factors, identification with tribal tradition, language spoken in the home, binge drinking, and depression screening results. RESULTS: Current smoking was more prevalent among men. In multivariate analysis, higher likelihood of current smoking was found for participants with these characteristics: younger, unmarried, low income, and increased frequency of binge drinking. For women, additional characteristics included no high school diploma and positive depression screening. Participants from southeastern Alaska were less likely to be current smokers. Current smokeless tobacco use rates were similar across gender. Higher likelihood of current smokeless use was found in southwestern Alaska and among those with positive depression screening. Women with low income and who reported at least some identification with tribal tradition had increased odds of current smokeless use. More than 20% of smokeless tobacco users reported initiating by age 10. DISCUSSION: Rates of tobacco use by AN people continue to be higher than other U.S. populations. Tobacco initiation prevention efforts targeting AN youth at an early age are recommended, given the early age of initiation demonstrated in this study.

Differences in cigarette and smokeless tobacco use among American Indian and Alaska Native people living in Alaska and the Southwest United States.

INTRODUCTION: This study analyzed self-reported tobacco use among American Indian and Alaska Native (AI/AN) people enrolled in the Education and Research Towards Health Study in Alaska (n = 3,821) and the Southwest United States (n = 7,505) from 2004 to 2006. METHODS: Participants (7,060 women and 4,266 men) completed a computer-assisted self-administered questionnaire on cigarette and smokeless tobacco (ST) use. RESULTS: Current use of cigarettes was considerably higher in Alaska than in the Southwest United States (32% vs. 8%). Current ST use was also more common in Alaska than in the Southwest United States (18% vs. 8%). Additionally, smoking was more common among men, younger age, those who were not married, and who only spoke English at home, while ST use was more common among men, those with lower educational attainment and those who spoke an AI/AN language at home (p < .01). Compared with the U.S. general population, AI/AN people living in Alaska were more likely and those living in the Southwest United States were less likely to be current smokers. Rates of ST use, including homemade ST, in both regions were much higher than the U.S. general population. DISCUSSION: Tobacco use among AI/AN people in the Southwest United States, who have a tradition of ceremonial tobacco use, was far lower than among Alaska Native people, who do not have a tribal tradition. Tobacco use is a key risk factor for multiple diseases. Reduction of tobacco use is a critical prevention measure to improve the health of AI/AN people.

Associations among body mass index, waist circumference, and health indicators in American Indian and Alaska Native adults.

PURPOSE: Little is known about obesity-related health issues among American Indian and Alaska Native (AIAN) populations. APPROACH: A large cohort of AIAN people was assembled to evaluate factors associated with health. SETTING: The study was conducted in Alaska and on the Navajo Nation. PARTICIPANTS: A total of 11,293 AIAN people were included. METHODS: We present data for body mass index (BMI, kg/m2) and waist circumference (cm) to evaluate obesity-related health factors. RESULTS: Overall, 32.4% of the population were overweight (BMI 25-29.9 kg/m2), 47.1% were obese (BMI > or = 30 kg/m2), and 21.4% were very obese (BMI, > or = 35 kg/m2). A waist circumference greater than 102 cm for men and greater than 88 cm for women was observed for 41.7% of men and 78.3% of women. Obese people were more likely to perceive their health as fair/poor than nonobese participants (prevalence ratio [PR], 1.91; 95% CI, 1.71-2.14). Participants younger than 30 years were three times more likely to perceive their health as being fair or poor when their BMI results were 35 or greater compared with those whose BMI results were less than 25 kg/m2. A larger BMI was associated with having multiple medical conditions, fewer hours of vigorous activity, and more hours of television watching. CONCLUSIONS: Given the high rates of obesity in AIAN populations and the association of obesity with other health conditions, it is important to reduce obesity among AIAN people.

Validation of a dietary history questionnaire for American Indian and Alaska Native people.

OBJECTIVE: We assessed reliability and relative validity of a self-administered computer-assisted dietary history questionnaire (DHQ) for use in a prospective study of diet, lifestyle, and chronic disease in American Indians in the Dakotas and Southwestern US and Alaska Native people. DESIGN: Reliability was assessed by one-month test-retest of the dietary history questionnaire. Validity was assessed by comparison of the weighted average of up to 12 monthly 24-hour recalls collected prospectively and a dietary history questionnaire completed in the 13th month. PARTICIPANTS: Participants were recruited at the baseline visit of the Education and Research Toward Health Study in Alaska, the Northern Plains and the Dakotas. RESULTS: Reliability (Pearson correlation) of the DHQ ranged from r = 0.43 for vitamin A density to r = 0.90 for energy intake. The association of nutrient and food estimates assessed by 24-hour recalls and the DHQ completed at the end of the year reflected no bias towards recent intake. Macronutrients expressed as density (nutrients per 1000 calories) did appear to be valid (r = 0.50-0.71) as did several micronutrients (range r = .22 to 0.59), fiber (r = 0.51), and servings of red meat (r = 0.67). However, the DHQ overestimated intake and gross amounts of nutrients were not strongly associated with the weighted average of the 24-hour recalls. CONCLUSIONS: The DHQ developed for estimation of dietary intake in American Indians and Native people in Alaska is reliable. Estimates of nutrient density appeared to have acceptable relative validity for use in epidemiologic studies.

Chronic disease risk factors among Alaska Native and American Indian people, Alaska, 2004-2006.

INTRODUCTION: The Alaska Education and Research Towards Health (EARTH) Study is being conducted to determine the prevalence of clinically measured chronic disease risk factors in a large population of American Indian/Alaska Native people (AI/AN). We report these estimates and compare them with those for the overall US population, as assessed by the National Health and Nutrition Examination Survey (NHANES). METHODS: We measured blood pressure, height, weight, and fasting serum lipids and glucose in a prospective cohort of 3,822 AI/AN participants who resided in Alaska during 2004 through 2006. We categorized participants as having chronic disease risk factors if their measurements exceeded cutoffs that were determined on the basis of national recommendations. We analyzed the prevalence of risk factors by sex and age and compared the age-adjusted prevalence with 1999-2004 NHANES measurements. RESULTS: EARTH participants were significantly more likely than NHANES participants to be overweight or obese and to have impaired fasting glucose, low high-density lipoprotein cholesterol, high low-density lipoprotein cholesterol, and hypertension. The prevalence of high total cholesterol and triglycerides was not significantly different between the 2 study populations. CONCLUSION: We provide baseline clinical measurements for chronic disease risk factors for a larger study sample than any previous study of AI/AN living in Alaska. The prevalence of most risk factors measured exceeded national rates. These data can be used to tailor health interventions and reduce health disparities.

Cancers of the breast, uterus, ovary and cervix among Alaska Native women, 1974-2003.

OBJECTIVES: Alaska Native (AN) women have exhibited some of the highest incidence rates of cancer overall, and different patterns of site-specific incidence compared to other U.S. populations. This study compares incidence rates between AN and U.S. white women (USW) for cancers of the breast, uterus, ovary and cervix, and examines effects of time period and birth cohort as determinants of incidence trends among AN women. STUDY DESIGN: Observational, population-based study. METHODS: Cancer incidence data from the Alaska Native Tumor Registry and SEERStat, 1974-2003. Age-adjusted World Standard Population rates were calculated for a current 5-year period and over time (30 years), and compared to other populations using rate ratios with 95% confidence intervals. Log-linear regression models used to assess impact on trend of age, time period and birth cohort. RESULTS: Compared to U.S. white women, current cancer rates among AN women are not significantly different for cancer of the breast and cervix, and significantly lower for cancers of the ovary and uterus. Trends over time over a 30-year time period also differ for these cancer sites. There were significant increases in breast and uterine cancer, and in contrast, a marked decline in cervical cancer. There was no significant change for cancer of the ovary. Changes appear to be due largely to period, not birth cohort effects. CONCLUSIONS: Increases in breast cancer may be due to a combination of modifiable behaviours; increased BMI and a shift to a non-traditional diet. Increases in uterine cancer could be associated with increased BMI and diabetes. Cervical cancer rates have declined to USW levels. The marked decline is likely due to enhanced screening and control efforts within the Alaska Native Women's cancers among Alaska Natives Tribal Health System (formerly Alaska Area USPHS, Indian Health Service utilizing resources available from the Centers for Disease Control tribal and state Breast and Cervical Cancer Early Detection Programs).

Stroke mortality among Alaska Native people.

OBJECTIVES: We aimed to describe the epidemiology of stroke among Alaska Natives, which is essential for designing effective stroke prevention and intervention efforts for this population. METHODS: We conducted an analysis of death certificate data for the state of Alaska for the period 1984 to 2003, comparing age-standardized stroke mortality rates among Alaska Natives residing in Alaska vs US Whites by age category, gender, stroke type, and time. RESULTS: Compared with US Whites, Alaska Natives had significantly elevated stroke mortality from 1994 to 2003 but not from 1984 to 1993. Alaska Native women of all age groups and Alaska Native men younger than 45 years of age had the highest risk, although the rates for those younger than 65 years were statistically imprecise. Over the 20-year study period, the stroke mortality rate was stable for Alaska Natives but declined for US Whites. CONCLUSIONS: Stroke mortality is higher among Alaska Natives, especially women, than among US Whites. Over the past 20 years, there has not been a significant decline in stroke mortality among Alaska Natives.