Spirituality and mental health status among Northern Plain tribes.

Spirituality measures often show positive associations with preferred mental health outcomes in the general population; however, research among American Indians (AIs) is limited. We examined the relationships of mental health status and two measures of spirituality - the Midlife Development Inventory (MIDI) and a tribal cultural spirituality measure - in Northern Plains AIs, aged 15-54 (n = 1636). While the MIDI was unassociated with mental health status, the tribal cultural spirituality measure showed a significant relationship with better mental health status. Mental health conditions disproportionately affect AIs. Understanding protective factors such as cultural spirituality that can mitigate mental health disorders is critical to reducing these health disparities.

Using PhotoVoice to Promote Land Conservation and Indigenous Well-Being in Oklahoma.

Indigenous ancestral teachings commonly present individual and community health as dependent upon relationships between human and nonhuman worlds. But how do persons conversant with ancestral teachings effectively convey such perspectives in contemporary contexts, and to what extent does the general tribal citizenry share them? Can media technology provide knowledge keepers with opportunities to communicate their perspectives to larger audiences? What are the implications for tribal citizens' knowledge and views about tribal land use policies? Using a PhotoVoice approach, we collaborated with a formally constituted body of Cherokee elders who supply cultural guidance to the Cherokee Nation government in Oklahoma. We compiled photographs taken by the elders and conducted interviews with them centered on the project themes of land and health. We then developed a still-image documentary highlighting these themes and surveyed 84 Cherokee citizens before and after they viewed it. Results from the pre-survey revealed areas where citizens' perspectives on tribal policy did not converge with the elders' perspectives; however, the post-survey showed statistically significant changes. We conclude that PhotoVoice is an effective method to communicate elders' perspectives, and that tribal citizens' values about tribal land use may change as they encounter these perspectives in such novel formats.

Prevalence and Indicators of Household Smoking Bans Among American Indians.

More than 58 million nonsmokers in the U.S. encounter secondhand smoke that leads to tobacco-related diseases and deaths every year, making voluntary household smoking bans an important public health goal. American Indians/Alaska Natives are rarely included in research related to household smoking bans. Further, most studies dichotomize household smoking bans into complete bans versus partial/no bans, rendering it impossible to determine if partial and no bans are associated with different or similar risk factors. Using the 2014 Cherokee Nation American Indian Adult Tobacco Survey, our study sought to identify prevalence of household smoking bans, their extent, and their correlates in an American Indian population. This cross-sectional analysis used multinomial logistic regression to determine correlates of complete, partial, and no household smoking bans. Results indicated that approximately 84% of Cherokee households have a complete ban. Younger age, female gender, higher education, higher household income, respondent's nonsmoking status, good health, better awareness of harms related to secondhand smoke, visits with a healthcare provider within the past year, and children in the home were positively and significantly associated with complete household smoking bans. Additionally, there were notable differences between correlates related to partial bans and no bans. These results provide insight for the development of more appropriate interventions for American Indian households that do not have a complete household smoking ban.

Health Literacy and Informed Consent Materials: Designed for Documentation, Not Comprehension of Health Research.

Minority populations with health disparities are underrepresented in research designed to address those disparities. One way to improve minority representation is to use community-based participatory methods to overcome barriers to research participation, beginning with the informed consent process. Relevant barriers to participation include lack of individual or community awareness or acceptance of research processes and purposes. These barriers are associated with limited health literacy. To inform recommendations for an improved consent process, we examined 97 consent documents and 10 associated Institutional Review Board websites to determine their health literacy demands and degree of adherence to principles of community-based research. We assessed the reading level of consent documents and obtained global measures of their health literacy demand by using the Suitability and Comprehensibility Assessment of Materials instrument. Although these documents were deemed suitable as medical forms, their readability levels were inappropriate, and they were unsuitable for educating potential participants about research purposes. We also assessed consent forms and Institutional Review Board policies for endorsement of community-based participatory principles, finding that very few acknowledged or adhered to such principles. To improve comprehension of consent documents, we recommend restructuring them as educational materials that adhere to current health literacy guidelines.

Low-level inorganic arsenic exposure and neuropsychological functioning in American Indian elders.

BACKGROUND: Inorganic arsenic at high and prolonged doses is highly neurotoxic. Few studies have evaluated whether long-term, low-level arsenic exposure is associated with neuropsychological functioning in adults. OBJECTIVES: To investigate the association between long-term, low-level inorganic arsenic exposure and neuropsychological functioning among American Indians aged 64-95. METHODS: We assessed 928 participants in the Strong Heart Study by using data on arsenic species in urine samples collected at baseline (1989-1991) and results of standardized tests of global cognition, executive functioning, verbal learning and memory, fine motor functioning, and speed of mental processing administered during comprehensive follow-up evaluations in 2009-2013. We calculated the difference in neuropsychological functioning for a 10% increase in urinary arsenic with adjustment for sex, age, education, and study site. RESULTS: The sum of inorganic and methylated arsenic species (∑As) in urine was associated with limited fine motor functioning and processing speed. A 10% increase in ∑As was associated with a .10 (95% CI -.20, -.01) decrease on the Finger Tapping Test for the dominant hand and a .13 decrease (95% CI -.21, -.04) for the non-dominant hand. Similarly, a 10% increase in ∑As was associated with a .15 (95% CI -.29, .00) decrease on the Wechsler Adult Intelligence Scale-Fourth Edition Coding Subtest. ∑As was not associated with other neuropsychological functions. CONCLUSIONS: Findings indicate an adverse association between increased urinary arsenic fine motor functioning and processing speed, but not with other neuropsychological functioning, among elderly American Indians.

Patient and Provider Factors Associated With American Indian and Alaska Native Adolescent Tobacco Use Screening.

INTRODUCTION: Tobacco use is the leading behavioral cause of death among adults 25 years or older. American Indian (AI) and Alaska Native (AN) communities confront some of the highest rates of tobacco use and of its sequelae. Primary care-based screening of adolescents is an integral step in the reduction of tobacco use, yet remains virtually unstudied. We examined whether delivery of tobacco screening in primary care visits is associated with patient and provider characteristics among AI/AN adolescents. METHODS: We used a cross-sectional analysis to examine tobacco screening among 4757 adolescent AI/AN patients served by 56 primary care providers at a large tribally managed health system between October 1, 2011 and May 31, 2014. Screening prevalence was examined in association with categorical patient characteristics (gender, age, clinic visited, insurance coverage) and provider characteristics (gender, age, tenure) using multilevel logistic regressions with individual provider identity as the nesting variable. RESULTS: Thirty-seven percent of eligible patients were screened. Gender of both providers and patients was associated with screening. Male providers delivered screening more often than female providers (odds ratio [OR] 1.6, 95% confidence interval [CI] 0.7-3.9). Male patients had 20% lower odds of screening receipt (OR 0.8, 95% CI 0.7-0.9) than female patients, independent of patient age and provider characteristics. Individual provider identity significantly contributed to variability in the mixed-effects model (variance component 2.2; 95% CI 1.4-3.4), suggesting individual provider effect. CONCLUSIONS: Low tobacco screening delivery by female providers and the low receipt of screening among younger, male patients may identify targets for screening interventions.

Transdisciplinary cardiovascular and cancer health disparities training: experiences of the centers for population health and health disparities.

The Centers for Population Health and Health Disparities program promotes multilevel and multifactorial health equity research and the building of research teams that are transdisciplinary. We summarized 5 areas of scientific training for empowering the next generation of health disparities investigators with research methods and skills that are needed to solve disparities and inequalities in cancer and cardiovascular disease. These areas include social epidemiology, multilevel modeling, health care systems or health care delivery, community-based participatory research, and implementation science. We reviewed the acquisition of the skill sets described in the training components; these skill sets will position trainees to become leaders capable of effecting significant change because they provide tools that can be used to address the complexities of issues that promote health disparities.

Association of American Indian cultural identity with physical activity.

OBJECTIVE: Cultural factors are associated with health behaviors among American Indians. Accordingly, the objective of our study was to investigate whether cultural identity, defined as the primary language spoken at home, is associated with: 1) higher total physical activity levels, and 2) levels of leisure-time physical activity recommended for health benefits in a diverse sample of American Indians. DESIGN: Cross-sectional analysis of 5,207 American Indian adults 18 to 82 years. Participants resided on the Oglala Sioux (n=2,025) and Cheyenne River Sioux (n=1,528) reservations in South Dakota, and the Gila River Indian Community (n=1,654) in Arizona. RESULTS: Bicultural participants in South Dakota, but not Arizona, reported significantly higher total physical activity compared to the English-only group (P<.05). About 35% of English only speakers, 39% of American Indian/Alaska Native only speakers, and 39% of participants speaking both languages met the 150 minutes/week activity threshold. Odds of being sufficiently active were higher among bicultural respondents in both regions when compared to respondents endorsing only English, controlling for sociodemographic and health-related covariates (P<.05). CONCLUSION: Bicultural respondents among tribal members in South Dakota had significantly higher total physical activity, and higher levels of sufficient leisure-time activity in both South Dakota and Arizona, compared to those who spoke either language exclusively. Interventions that encourage American Indians to develop their bicultural efficacy and to draw on resources for healthy living that may be available in all the cultures with which they identify are recommended.

Religio-Spiritual Participation in Two American Indian Populations.

Following a previous investigation of religio-spiritual beliefs in American Indians, this article examined prevalence and correlates of religio-spiritual participation in two tribes in the Southwest and Northern Plains (N = 3,084). Analysis suggested a "religious profile" characterized by strong participation across three traditions: aboriginal, Christian, and Native American Church. However, sociodemographic variables that have reliably predicted participation in the general American population, notably gender and age, frequently failed to achieve significance in multivariate analyses for each tradition. Religio-spiritual participation was strongly and significantly related to belief salience for all traditions. Findings suggest that correlates of religious participation may be unique among American Indians, consistent with their distinctive religious profile. Results promise to inform researchers' efforts to understand and theorize about religio-spiritual behavior. They also provide tribal communities with practical information that might assist them in harnessing social networks to confront collective challenges through community-based participatory research collaborations.

Cultural identity and patient trust among older American Indians.

BACKGROUND: Patients' trust in healthcare providers and institutions has been identified as a likely contributor to racial-ethnic health disparities. The likely influence of patients' cultural characteristics on trust is widely acknowledged but inadequately explored. OBJECTIVE: To compare levels of patients' trust in primary care provider (interpersonal trust) with trust in healthcare organizations (institutional trust) among older American Indians (AIs), and determine associations with cultural identity. DESIGN: Patient survey administered following primary care visits. PARTICIPANTS: Two-hundred and nineteen American Indian patients ≥ 50 years receiving care for a non-acute condition at two clinics operated by the Cherokee Nation in northeastern Oklahoma. MAIN MEASURES: Self-reported sociodemographic and cultural characteristics. Trust was measured using three questions about interpersonal trust and one measure of institutional trust; responses ranged from strongly agree to strongly disagree. Finding substantial variation only in institutional trust, we used logistic generalized estimating equations to examine relationships of patient cultural identity with institutional trust. KEY RESULTS: Ninety-five percent of patients reported trusting their individual provider, while only 46 % reported trusting their healthcare institution. Patients who strongly self-identified with an AI cultural identity had significantly lower institutional trust compared to those self-identifying less strongly (OR: 0.6, 95 % CI: 0.4, 0.9). CONCLUSIONS: Interpersonal and institutional trust represent distinct dimensions of patients' experience of care that may show important relationships to patients' cultural characteristics. Strategies for addressing low institutional trust may have special relevance for patients who identify strongly with AI culture.

A comparison of colorectal cancer screening uptake among average-risk insured American Indian/Alaska Native and white women.

INTRODUCTION: American Indian and Alaska Native (AI/AN) women have among the lowest rates of colorectal cancer (CRC) screening. Whether screening disparities persist with equal access to health care is unknown. METHODS: Using administrative data from 1996-2007, we compared CRC screening events for 286 AI/AN and 14,042 White women aged 50 years and older from a health maintenance organization in the Pacific Northwest of the U.S. RESULTS: The proportion of AI/AN and White women screened for CRC at age 50 was similar (13.3% vs. 14.0%, p =.74). No differences were seen in the type of screening test. Time elapsed to first screening among AI/AN women who were not screened at age 50 did not differ from White women (hazard ratio 1.0, 95% confidence interval 0.8-1.3). CONCLUSIONS: Uptake for CRC screening was similar among insured AI/AN and White women, suggesting that when access to care is equal, racial disparities in screening diminish.

Trauma and conditional risk of posttraumatic stress disorder in two American Indian reservation communities.

PURPOSE: To determine conditional risk of posttraumatic stress disorder (PTSD) in two culturally distinct American Indian reservation communities. METHOD: Data derived from the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project, a cross-sectional population-based survey that was completed between 1997 and 2000. This study focused on 1,967 participants meeting the DSM-IV criteria for trauma exposure. Traumas were grouped into interpersonal, non-interpersonal, witnessed, and "trauma to close others" categories. Analyses examined distribution of worst traumas, conditional rates of PTSD following exposure, and distributions of PTSD cases deriving from these events. Bivariate and multivariate logistic regressions estimated associations of lifetime PTSD with trauma type. RESULTS: Overall, 15.9 % of those exposed to DSM-IV trauma qualified for lifetime PTSD, a rate comparable to similar US studies. Women were more likely to develop PTSD than were men. The majority (60 %) of cases of PTSD among women derived from interpersonal trauma exposure (in particular, sexual and physical abuse); among men, cases were more evenly distributed across trauma categories. CONCLUSIONS: Previous research has demonstrated higher rates of both trauma exposure and PTSD in American Indian samples compared to other Americans. This study shows that conditional rates of PTSD are similar to those reported elsewhere, suggesting that the elevated prevalence of this disorder in American Indian populations is largely due to higher rates of trauma exposure.

Food Insecurity and Obesity Among American Indians and Alaska Natives and Whites in California.

Food insecurity is linked to obesity among some, but not all, racial and ethnic populations. We examined the prevalence of food insecurity and the association between food insecurity and obesity among American Indians (AIs) and Alaska Natives (ANs) and a comparison group of whites. Using the 2009 California Health Interview Survey, we analyzed responses from 592 AIs/ANs and 7371 white adults with household incomes at or below 200% of the federal poverty level. Food insecurity was measured using a standard 6-item scale. Sociodemographics, exercise, and obesity were all obtained using self-reported survey data. Logistic regression was used to estimate associations. The prevalence of food insecurity was similar among AIs/ANs and whites (38.7% vs 39.3%). Food insecurity was not associated with obesity in either group in analyses adjusted for sociodemographics and exercise. The ability to afford high-quality foods is extremely limited for low-income Californians regardless of race. Health policy discussions must include increased attention on healthy food access among the poor, including AIs/ANs, for whom little data exist.

Affective interactions in medical visits: ethnic differences among American Indian older adults.

OBJECTIVE: Investigate influence of ethnicity on older American Indian patients' interpretations of providers' affective behaviors. METHOD: Using data from 115 older American Indian patients, random effects ordered logit models related patient ratings of providers' respect, empathy, and rapport first to separate measures of American Indian and White American ethnicity, then to "ethnic discordance," or difference between providers' and patients' cultural characteristics. RESULTS: In models accounting for patients' ethnicity only, high scores for American Indian ethnicity were linked to reduced evaluations for providers' respect; high scores on White ethnicity were associated with elevated ratings for empathy and rapport. In models accounting for provider-patient ethnic discordance, high discordance on either ethnicity scale was associated with reduced ratings for the same behaviors. DISCUSSION: Findings support "orthogonal ethnic identity" theory and extend "cultural health capital" theory, suggesting a pathway by which ethnicity becomes relevant to experience of health care among older adults.

Effect of tribal language use on colorectal cancer screening among American Indians.

American Indians have one of the lowest colorectal cancer (CRC) screening rates for any racial/ethnic group in the U.S., yet reasons for their low screening participation are poorly understood. We examine whether tribal language use is associated with knowledge and use of CRC screening in a community-based sample of American Indians. Using logistic regression to estimate the association between tribal language use and CRC test knowledge and receipt we found participants speaking primarily English were no more aware of CRC screening tests than those speaking primarily a tribal language (OR = 1.16 [0.29, 4.63]). Participants who spoke only a tribal language at home (OR = 1.09 [0.30, 4.00]) and those who spoke both a tribal language and English (OR = 1.74 [0.62, 4.88]) also showed comparable odds of receipt of CRC screening. Study findings failed to support the concept that use of a tribal language is a barrier to CRC screening among American Indians.

Culture and colorectal cancer screening on three American Indian reservations.

BACKGROUND: Colorectal cancer (CRC) rates among many American Indian populations are high. Screening by fecal occult blood test (FOBT) and endoscopy is effective for reducing CRC mortality, but little research has examined the extent of such screening in reservation populations. Further, nothing is known of how American Indians' cultural characteristics may be related to screening receipt. PARTICIPANTS AND SETTING: We examined data from participants recruited from 2 Northern Plains and 1 Southwest reservation for the Education and Research Toward Health (EARTH) study. All participants aged > or = 51 years were eligible for inclusion. DESIGN: After calculating screening rates, we examined bivariate relationships between screening and participant characteristics, including measures of cultural characteristics including ethnic identity and use of traditional healing practices. We applied multivariate regression to relate these cultural variables to odds of lifetime screening by FOBT or endoscopy. RESULTS: Of 751 American Indians sampled, 35% reported lifetime CRC screening by at least one modality. Multivariate analyses did not reveal significant relationships or trends relating FOBT to respondents' cultural characteristics. By contrast, odds of endoscopy were significantly lower among persons who spoke a tribal language at home (OR .6, 95% C.I. .4-.9), and trend analysis revealed an inverse relationship between endoscopy and number of identity measures endorsed (Ptrend<.1). CONCLUSIONS: The sampled population exhibits disparities in CRC compared to the general population, and cultural characteristics are related to odds of endoscopy. Findings warrant culturally tailored CRC screening initiatives for American Indians.

Theory and practice in participatory research: lessons from the Native Elder Care Study.

Models for community-based participatory research (CBPR) urge academic investigators to collaborate with communities to identify and pursue research questions, processes, and outcomes valuable to both partners. The tribal participatory research (TPR) conceptual model suggests modifications to CBPR to fit the special needs of American Indian communities. This paper draws upon authors' collaboration with one American Indian tribe to recommend theoretical revision and practical strategies for conducting gerontological research in tribal communities. We rated the TPR model as a strong, specialized adaptation of participatory research principles. Although the need for some TPR mechanisms may vary, our experience recommends incorporating dissemination as a central TPR mechanism. Researchers and communities can expect well-crafted collaborative projects to generate particular types of positive project outcomes for both partners, but should prepare for both predictable and unique challenges.

A review of the experience, epidemiology, and management of pain among American Indian, Alaska Native, and Aboriginal Canadian peoples.

UNLABELLED: Substantial literature suggests that diverse biological, psychological, and sociocultural mechanisms account for differences by race and ethnicity in the experience, epidemiology, and management of pain. Many studies have examined differences between Whites and minority populations, but American Indians (AIs), Alaska Natives (ANs), and Aboriginal peoples of Canada have been neglected both in studies of pain and in efforts to understand its biopsychosocial and cultural determinants. This article reviews the epidemiology of pain and identifies factors that may affect clinical assessment and treatment in these populations. We searched for peer-reviewed articles focused on pain in these populations, using PubMed, CINAHL, Cochrane, and the University of New Mexico Native Health Database. We identified 28 articles published 1990 to 2009 in 3 topic areas: epidemiology of pain, pain assessment and treatment, and healthcare utilization. A key finding is that AI/ANs have a higher prevalence of pain symptoms and painful conditions than the U.S. general population. We also found evidence for problems in provider-patient interactions that affect clinical assessment of pain, as well as indications that AI/AN patients frequently use alternative modalities to manage pain. Future research should focus on pain and comorbid conditions and develop conceptual frameworks for understanding and treating pain in these populations. PERSPECTIVE: We reviewed the literature on pain in AI/ANs and found a high prevalence of pain and painful conditions, along with evidence of poor patient-provider communication. We recommend further investigation of pain and comorbid conditions and development of conceptual frameworks for understanding and treating pain in this population.

Perceived cancer risk among American Indians: implications for intervention research.

OBJECTIVE: Perceived risk of disease plays a key role in health behaviors, making it an important issue for cancer-prevention research. We investigate associations between perceived cancer risk and selected cancer risk factors in a population-based sample of American Indians. STUDY DESIGN AND POPULATION: Data for this cross-sectional study come from a random sample of 182 American Indian adults, aged > or = 40 years, residing on the Hopi Reservation in northeastern Arizona. OUTCOME MEASURES: Perception of cancer risk was ascertained with the 5-point Likert scale question, "How likely do you think it is that you will develop cancer in the future?" dichotomized into low perceived risk and high perceived risk. RESULTS: Participants reporting a family member with cancer were more likely, by greater than five times, to report the perception that they would get cancer (OR = 5.3; 95% CI: 2.3, 12.3). After controlling for age and family history of cancer, knowledge of cancer risk factors and attitude about cancer prevention were not significantly associated with risk perception. CONCLUSIONS: Perceived cancer risk was significantly associated with self-reported family history of cancer, supporting the importance of personal knowledge of cancer among American Indians. Further research is needed to obtain a more complete picture of the factors associated with perceptions of cancer risk among American Indians in order to develop effective interventions.

Religiosity and Spiritual Engagement in Two American Indian Populations.

Social scientific investigation into the religiospiritual characteristics of American Indians rarely includes analysis of quantitative data. After reviewing information from ethnographic and autobiographical sources, we present analyses of data from a large, population-based sample of two tribes (n = 3,084). We examine salience of belief in three traditions: aboriginal, Christian, and Native American Church. We then investigate patterns in sociodemographic subgroups, determining the significant correlates of salience with other variables controlled. Finally, we examine frequency with which respondents assign high salience to only one tradition (exclusivity) or multiple traditions (nonexclusivity), again investigating subgroup variations. This first detailed, statistical portrait of American Indian religious and spiritual lives links work on tribal ethnic identity to theoretical work on America's "religious marketplace." Results may also inform social/behavioral interventions that incorporate religiospiritual elements.