"Sorry for laughing, but it's scary": humor and silence in discussions of Colorectal Cancer with Urban American Indians.

BACKGROUND: Given high rates of cancer mortality in Native communities, we examined how urban American Indian and Alaska Native elders talk about colorectal cancer (CRC) and CRC screening. METHODS: We conducted seven focus groups with a total of 46 participants in two urban clinics in the Pacific Northwest to assess participant awareness, perceptions, and concerns about CRC and CRC screening. Using speech codes theory, we identified norms that govern when and how to talk about CRC in this population. RESULTS: Our analyses revealed that male participants often avoided screening because they perceived it as emasculating, whereas women often avoided screening because of embarrassment and past trauma resulting from sexual abuse. Both men and women used humor to mitigate the threatening nature of discussions about CRC and CRC screening. CONCLUSIONS: We offer our analytic results to assist others in developing culturally appropriate interventions to promote CRC screening among American Indians and Alaska Natives.

Health Disparities Research Among Small Tribal Populations: Describing Appropriate Criteria for Aggregating Tribal Health Data.

In response to community concerns, we used the Tribal Participatory Research framework in collaboration with 5 American-Indian communities in Washington, Idaho, and Montana to identify the appropriate criteria for aggregating health data on small tribes. Across tribal sites, 10 key informant interviews and 10 focus groups (n = 39) were conducted between July 2012 and April 2013. Using thematic analysis of focus group content, we identified 5 guiding criteria for aggregating tribal health data: geographic proximity, community type, environmental exposures, access to resources and services, and economic development. Preliminary findings were presented to focus group participants for validation at each site, and a culminating workshop with representatives from all 5 tribes verified our final results. Using this approach requires critical assessment of research questions and study designs by investigators and tribal leaders to determine when aggregation or stratification is appropriate and how to group data to yield robust results relevant to local concerns. At project inception, tribal leaders should be consulted regarding the validity of proposed groupings. After regular project updates, they should be consulted again to confirm that findings are appropriately contextualized for dissemination.

Conversations about Community-Based Participatory Research and Trust: "We Are Explorers Together".

BACKGROUND: This paper describes a study circle and a series of conversations with a community partner that were part of a project that grew out of a partnership between Native People for Cancer Control, a research program at the University of Washington, and five tribes in Washington, Idaho, and Montana. METHODS: Researchers undertook a study circle to build bioethics capacity and, specifically, to better understand the values that should guide community-based participatory research (CBPR). RESULTS: Study circle members identified five action guiding principles for CBPR: respect tribal sovereignty, promote transparency, hear community priorities, learn from each other, and take collective action. This activity led to a series of conversations between researchers and the chair of Shoalwater Bay Tribe, Charlene Nelson. Nelson suggests the metaphor of "exploration" as a way to think about what good CBPR looks like. Exploration reframes the research enterprise, from a systematic scientific inquiry conducted by academic investigators to a less predictable activity that reaches into the uncontrolled and unknown. We used this metaphor to explore three features of CBPR we believe to be essential to building trust: ongoing commitment and time, direct collaboration with community members and new learning for all involved, and candid and cautious action. CONCLUSIONS: The CBPR literature underscores many of these same points; however, we found the metaphorical language offered by Nelson enriched their meaning and deepened study circle members' appreciation of them.

Sexual health screening in people living with HIV--are we getting the whole story?

Patients' notes were audited to evaluate sexual health screening in 385 people living with HIV. A total of 76% were offered sexually transmitted infection (STI) screening; 85% of these accepted; 62% reported regular partners of whom 44% were also people living with HIV. In men who have sex with men (MSM), 64% reported consistent condom use for anal sex; of these, 15% had rectal STIs diagnosed. Of all patients, 62% reported monogamous relationships; in this MSM sub-group, 12% had STIs diagnosed. STIs are still being diagnosed despite continued safe sex messages and significantly in those reporting monogamous relationships and consistent condom use. Sexual history and safe sex education should be integral to routine care and STI screening offered annually regardless of sexual history as recommended by 2013 British HIV Association Standards of Care for People Living with HIV. More frequent STI screening may be required in high-risk patients.

A national study of social networks and perceptions of health among urban American Indian/Alaska Natives and non-Hispanic Whites.

Using data from The National Epidemiologic Survey on Alcohol and Related Conditions, the strength of social networks and the association of self-reported health among American Indians and Alaska Natives (AI/AN) and non-Hispanic Whites (NHW) were compared. Differences in social network-health relationships between AI/ANs and NHWs were also examined. For both groups, those with fewer network members were more likely to report fair or poor health than those with average or more network members, and persons with the fewest types of relationships had worse self-reported health than those with the average or very diverse types of relationships. Furthermore, small social networks were associated with much worse self-reported health in AI/ANs than in NHWs.

Posttraumatic stress disorder and symptoms among American Indians and Alaska Natives: a review of the literature.

PURPOSE: American Indians and Alaska Natives (AI/ANs) experience high rates of trauma and posttraumatic stress disorder (PTSD). We reviewed existing literature to address three interrelated questions: (1) What is the prevalence of PTSD and PTSD symptoms among AI/ANs? (2) What are the inciting events, risk factors, and co-morbidities in AI/ANs, and do they differ from those in the general U.S. population? (3) Are studies available to inform clinicians about the course and treatment of PTSD in this population? METHODS: We searched the PubMed and Web of Science databases and a database on AI/AN health, capturing an initial sample of 77 original English-language articles published 1992­2010. After applying exclusion criteria, we retained 37 articles on prevalence of PTSD and related symptoms among AI/AN adults. We abstracted key information and organized it in tabular format. RESULTS: AI/ANs experience a substantially greater burden of PTSD and related symptoms than U.S. Whites. Combat experience and interpersonal violence were consistently cited as leading causes of PTSD and related symptoms. PTSD was associated with bodily pain, lung disorders, general health problems, substance abuse, and pathological gambling. In general, inciting events, risk factors, and co-morbidities appear similar to those in the general U.S. population. CONCLUSIONS: Substantial research indicates a strikingly high incidence of PTSD in AI/AN populations. However, inciting events, risk factors, and co-morbidities in AI/ANs, and how they may differ from those in the general population, are poorly understood. Very few studies are available on the clinical course and treatment of PTSD in this vulnerable population.

"Our culture is medicine": perspectives of Native healers on posttrauma recovery among American Indian and Alaska Native patients.

American Indian and Alaska Native (Native) people experience more traumatic events and are at higher risk for developing posttraumatic stress disorder compared with the general population. We conducted in-depth interviews with six Native healers about their perspectives on traumatic injury and healing. We analyzed the interviews using an inductive approach to identify common themes. We categorized these themes into four categories: causes and consequences of traumatic injury, risk factors, protective factors, and barriers to care. The implications of our study include a need for improving cultural competence among health care and social services personnel working with Native trauma patients. Additional cumulative analyses of Native healers and trauma patients would contribute to a much-needed body of knowledge on improving recovery and promoting healing among Native trauma patients.