Clinical Outcomes from the Alaska Native Tribal Health Consortium Colorectal Cancer Control Program: 2009-2015.

The Alaska Native Tribal Health Consortium (ANTHC) participated in the United States Centers for Disease Control and Prevention Colorectal Cancer Control Program (CRCCP) from 2009 to 2015. We conducted a descriptive evaluation of ANTHC CRCCP demographics, quality measures, and clinical outcomes, including screening methods employed within the program and screening outcomes. There were 6981 program screenings completed, with the majority (81.3%) of people screened in the 50-75 year age group. Colonoscopy was the primary screening test used, accounting for 6704 (96.9%) of the screening tests. Quality of colonoscopy was high: adequate bowel preparation was reported in 98.2% of colonoscopies, cecal intubation rate was 98.9%, and the adenoma detection rate was 38.9%. A high proportion (58.9%) of colonoscopies had an initial finding of polyps or lesions suspicious for cancer; 41.2% of all colonoscopies had histological confirmation of either adenomatous polyps (40.6%) or cancer (0.5%). The ANTHC CRCCP successfully increased CRC screening among American Indian and Alaska Native peoples living in Alaska; this was achieved primarily through high-quality colonoscopy metrics. These data support a continued focus by the Alaska Native Tribal Health Consortium and its tribal health partners on increasing CRC screening and reducing cancer mortality among Alaska Native peoples.

Provider- and System-Level Barriers and Facilitators to Colonoscopy and Multi-Target Stool DNA for Colorectal Cancer Screening in Rural/Remote Alaska Native Communities.

The Alaska Tribal Health System is working to increase colorectal cancer (CRC) screening among Alaska Native people, who experience the highest CRC rates in the world. This study examined CRC screening provider- and system-level barriers and facilitators from the perspective of healthcare providers serving Alaska Native people in rural/remote communities. A total of 28 provider (physicians, advanced practice, and Community Health Aides/Practitioners) interviews were held from 1 February to 30 November 2021. Colonoscopy provider-level barrier themes included time, competing priorities, and staffing, while system-level barriers included travel costs, weather, and the COVID-19 pandemic. Multi-target stool DNA (mt-sDNA) barrier themes included test viability and unfamiliarity, and previous stool tests experiences. For both tests, limited medical record reminders was a major barrier. Facilitator themes for both tests included community outreach, cultural competency and patient navigation, and clinic/system improvements. In-depth interviews with tribal health providers showed that adding mt-sDNA testing may help address system-level colonoscopy barriers such as waitlists and travel costs, but other barriers remain. Further research is needed into patient barriers and facilitators, as well as the effectiveness of integrating mt-sDNA into a geographically dispersed tribal health system to reduce cancer disparities and build equity in CRC prevention among Alaska Native people.

Cancer Screening Prevalence among Participants in the Southcentral Alaska Education and Research towards Health (EARTH) Study at Baseline and Follow-Up.

Alaska Native communities are working to prevent cancer through increased cancer screening and early detection. We examined the prevalence of self-reported colorectal (CRC), cervical, and breast cancer screening among Alaska Native participants in the southcentral Alaska Education and Research toward Health (EARTH) study at baseline (2004-2006) and ten-year follow-up (2015-2017); participant characteristics associated with screening; and changes in screening prevalence over time. A total of 385 participants completed questionnaires at follow-up; 72% were women. Of those eligible for CRC screening, 53% of follow-up participants reported a CRC screening test within the past 5 years, significantly less than at baseline (70%) (p = 0.02). There was also a significant decline in cervical cancer screening between baseline and follow-up: 73% of women at follow-up vs. 90% at baseline reported screening within the past three years (p < 0.01). There was no significant difference in reported breast cancer screening between baseline (78%) and follow-up (77%). Colorectal and cervical cancer screening prevalence in an urban, southcentral Alaska Native cohort declined over 10 years of follow-up. Increased cancer screening and prevention are needed to decrease Alaska Native cancer-related morbidity and mortality.

Elevated colorectal cancer incidence among American Indian/Alaska Native persons in Alaska compared to other populations worldwide.

Colorectal cancer (CRC) is a leading cancer worldwide; incidence varies greatly by country and racial group. We compared 2018 American Indian/Alaska Native (AI/AN) CRC incidence rates in Alaska to other Tribal, racial, and international population rates. AI/AN persons in Alaska had the highest CRC incidence rate among US Tribal and racial groups (61.9/100,000 in 2018). AI/AN persons in Alaska also had higher rates than those reported for any other country in the world in 2018 except for Hungary, where males had a higher CRC incidence rate than AI/AN males in Alaska (70.6/100,000 and 63.6/100,000 respectively). This review of CRC incidence rates from populations in the United States and worldwide showed that AI/AN persons in Alaska had the highest documented incidence rate of CRC in the world in 2018. It is important to inform health systems serving AI/AN persons in Alaska about policies and interventions that can support CRC screening to reduce the burden of this disease.

Elevated Adenomatous Polyp Detection Rate Among Alaska Native and American Indian People in Interior Alaska, 2018-2022.

OBJECTIVES: Colorectal cancer (CRC) incidence and mortality are twice as high among Alaska Native people as among non-Hispanic White people in the United States; as such, colonoscopy is a recommended screening test for Alaska Native people. Adenoma detection rate (ADR) is measured in patients at average risk of CRC undergoing initial screening colonoscopy and reflects the prevalence of precancerous polyps in a screened population. We evaluated the ADR among Alaska Native people living in Interior Alaska. METHODS: This project evaluated the ADR among Alaska Native and American Indian adults aged ≥40 years (N = 460) living in Interior Alaska, using a retrospective medical record review of patients referred for screening colonoscopy from February 1, 2018, through March 31, 2022. The main outcome measure was ADR, stratified by age and sex. RESULTS: The ADR was 45.0% overall: 43.0% among women and 47.1% among men. Among patients aged ≥50 years, the ADR was 67.1%: 62.7% among women and 70.7% among men. Among patients aged 40-49 years, the ADR was 34.4%: 35.3% among women and 33.3% among men. CONCLUSIONS: Measured ADR was high among Alaska Native men and women aged ≥50 years in Interior Alaska and in all age groups that were screened. These findings have implications for which CRC screening methods, intervals, and age to begin screening are most appropriate for Alaska Native people, as well as the need for future research on the pathology, etiology, and natural history of CRC in this population.

Cancer statistics for American Indian and Alaska Native individuals, 2022: Including increasing disparities in early onset colorectal cancer.

American Indian and Alaska Native (AIAN) individuals are diverse culturally and geographically but share a high prevalence of chronic illness, largely because of obstacles to high-quality health care. The authors comprehensively examined cancer incidence and mortality among non-Hispanic AIAN individuals, compared with non-Hispanic White individuals for context, using population-based data from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries. Overall cancer rates among AIAN individuals were 2% higher than among White individuals for incidence (2014 through 2018, confined to Purchased/Referred Care Delivery Area counties to reduce racial misclassification) but 18% higher for mortality (2015 through 2019). However, disparities varied widely by cancer type and geographic region. For example, breast and prostate cancer mortality rates are 8% and 31% higher, respectively, in AIAN individuals than in White individuals despite lower incidence and the availability of early detection tests for these cancers. The burden among AIAN individuals is highest for infection-related cancers (liver, stomach, and cervix), for kidney cancer, and for colorectal cancer among indigenous Alaskans (91.3 vs. 35.5 cases per 100,000 for White Alaskans), who have the highest rates in the world. Steep increases for early onset colorectal cancer, from 18.8 cases per 100,000 Native Alaskans aged 20-49 years during 1998 through 2002 to 34.8 cases per 100,000 during 2014 through 2018, exacerbated this disparity. Death rates for infection-related cancers (liver, stomach, and cervix), as well as kidney cancer, were approximately two-fold higher among AIAN individuals compared with White individuals. These findings highlight the need for more effective strategies to reduce the prevalence of chronic oncogenic infections and improve access to high-quality cancer screening and treatment for AIAN individuals. Mitigating the disparate burden will require expanded financial support of tribal health care as well as increased collaboration and engagement with this marginalized population.

Development of a colorectal cancer screening intervention for Alaska Native people during a pandemic year.

Objectives: Alaska Native (AN) people experience twice the rate of colorectal cancer (CRC) as US Whites. There is a need for increased screening and early detection. We describe the development and implementation of a randomized controlled trial of the multi-target stool DNA test (mt-sDNA; Cologuard® Exact Sciences, Madison WI) to increase CRC screening among AN people. Methods: A total of 32 rural/remote AN communities were randomized to a varied intensity intervention (patient navigation vs mailed health education) compared to 14 communities receiving usual opportunistic care. Outcome measures include screening completion and method used (mt-sDNA vs colonoscopy). Health care provider interviews and AN patient focus groups will be used to assess patient-, provider-, and system-level CRC screening promoters and barriers. Results: The study began in April 2020 during the COVID-19 pandemic, resulting in a number of challenges and study adaptations. These included difficulty finding laboratory space, lack of timely mail service due to flight reductions across the state, and travel restrictions that led to postponement of in-person focus groups. Videoconferencing platforms for Tribal engagement replaced face-to-face interactions. After an extensive search, a laboratory with space available was identified and the preprocessing laboratory established. Study staff will work closely with patients to monitor mail service to get mt-sDNA kits sent on time. We are also exploring the use of videoconferencing platforms as alternatives to in-person focus groups. Conclusions: Despite the challenges encountered during the COVID-19 pandemic, we successfully initiated the intervention and established the first mt-sDNA preprocessing laboratory in Alaska.

Smoking Patterns Among Urban Alaska Native and American Indian Adults: The Alaska EARTH 10-Year Follow-up Study.

INTRODUCTION: Data on cigarette smoking prevalence among Alaska Native and American Indian (ANAI) people are limited to cross-sectional studies or specific subpopulations. Using data from the Alaska Education and Research toward Health (EARTH) Study 10-year follow-up, this study assessed patterns of smoking from baseline and factors associated with current use. AIMS AND METHODS: EARTH Study urban south central ANAI participants (N = 376; 73% women) provided questionnaire data on smoking at baseline and 10-year follow-up. Multivariable-adjusted logistic regression assessed whether gender, cultural factors (Tribal identity, language spoken in the home), depressive symptoms (PHQ-9), baseline smoking status, and baseline cigarettes per day (CPD) were associated with current smoking at follow-up. RESULTS: Current smoking was 27% and 23% at baseline and follow-up, respectively. Of baseline smokers, 60% reported smoking at follow-up (77% men, 52% women). From multivariable-adjusted analyses, the odds of current smoking at follow-up were lower among women than men, those who never or formerly smoked versus currently smoked at baseline, and smoking <10 CPD compared with ≥10 CPD at baseline. PHQ-9 score or cultural variables were not associated with smoking at follow-up. Smoking fewer baseline CPD was associated with former smoking status (ie, quitting) at follow-up among women, but not men. CONCLUSIONS: Our project is among the first to longitudinally explore smoking within an ANAI cohort. While we observed persistent smoking during a 10-year period, there were important differences by gender and CPD in quitting. These differences may be important to enhance the reach and efficacy of cessation interventions for ANAI people. IMPLICATIONS: This study contributes novel longitudinal information on cigarette smoking prevalence during a 10-year period among Alaska Native and American Indian (ANAI) people. Prior data on smoking prevalence among ANAI people are limited to cross-sectional studies or specific subpopulations. Our project is among the first to longitudinally explore smoking prevalence within an ANAI cohort. We observed persistent smoking during a 10-year period. The study also contributes information on differences by gender and cigarettes smoked per day in quitting. These findings have implications for enhancing the reach and efficacy of cessation interventions for ANAI people.

Cost-Effectiveness of Multitarget Stool DNA Testing vs Colonoscopy or Fecal Immunochemical Testing for Colorectal Cancer Screening in Alaska Native People.

OBJECTIVE: To estimate the cost-effectiveness of multitarget stool DNA testing (MT-sDNA) compared with colonoscopy and fecal immunochemical testing (FIT) for Alaska Native adults. PATIENTS AND METHODS: A Markov model was used to evaluate the 3 screening test effects over 40 years. Outcomes included colorectal cancer (CRC) incidence and mortality, costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). The study incorporated updated evidence on screening test performance and adherence and was conducted from December 15, 2016, through November 6, 2019. RESULTS: With perfect adherence, CRC incidence was reduced by 52% (95% CI, 46% to 56%) using colonoscopy, 61% (95% CI, 57% to 64%) using annual FIT, and 66% (95% CI, 63% to 68%) using MT-sDNA. Compared with no screening, perfect adherence screening extends life by 0.15, 0.17, and 0.19 QALYs per person with colonoscopy, FIT, and MT-sDNA, respectively. Colonoscopy is the most expensive strategy: approximately $110 million more than MT-sDNA and $127 million more than FIT. With imperfect adherence (best case), MT-sDNA resulted in 0.12 QALYs per person vs 0.05 and 0.06 QALYs per person by FIT and colonoscopy, respectively. Probabilistic sensitivity analyses supported the base-case analysis. Under varied adherence scenarios, MT-sDNA either dominates or is cost-effective (ICERs, $1740-$75,868 per QALY saved) compared with FIT and colonoscopy. CONCLUSION: Each strategy reduced costs and increased QALYs compared with no screening. Screening by MT-sDNA results in the largest QALY savings. In Markov model analysis, screening by MT-sDNA in the Alaska Native population was cost-effective compared with screening by colonoscopy and FIT for a wide range of adherence scenarios.

Characteristics of colorectal cancers among Alaska Native people before and after implementing programs to promote screening.

BACKGROUND: Alaska Native (AN) people have the highest rates of colorectal cancer (CRC) globally. Increasing CRC screening has been effective in reducing CRC-related morbidity and mortality in other populations. OBJECTIVE: To examine recent descriptive epidemiology and longer-term CRC trends among AN people. To determine any changes in the descriptive epidemiology of CRC among AN people concurrent with increases in screening prevalence. METHODS: We estimated age-specific CRC incidence and mortality rates 2000-2017. To examine longer-term trends in incidence and mortality 1990-2017, we conducted Joinpoint regression analyses of three-year rolling average incidence and mortality rates. We calculated descriptive statistics for two time-periods: 2000-2008, and 2009-2017. Finally, we examined five-year survival probability. RESULTS: CRC incidence increased over time (1990-2017) among AN people aged less than 50 years, while there were modest declines in AN people older than 50 years old since 2000. Overall, AN CRC mortality rates declined between 1990 and 2004, but have been increasing steadily since that time. Comparing 2000-2008 with 2009-2017 we observed no difference in CRC incidence and mortality, age at diagnosis, tumor size, tumor location, or stage distribution. Survival analyses indicated no change in hazard of death between 2004-2008 and 2009-2017 (HR 1.02, 95 % CI: 0.74, 1.38, P = 0.93). CONCLUSIONS: Colorectal cancer prevention and control efforts across the Alaska Tribal Health System have not yet resulted in reduced mortality rates, or induced earlier stage migration. POLICY SUMMARY STATEMENT: Intensified efforts will be necessary to reduce the burden of CRC among this high-risk population. Continued and increased focus on primary and secondary prevention efforts is warranted.

Ten-year weight gain is not associated with multiple cardiometabolic measures in Alaska EARTH study participants.

BACKGROUND AND AIMS: Alaska Native (AN) traditional lifestyle may be protective against chronic disease risk. Weight gain in adulthood has been linked to increases in chronic disease risk among other populations; yet, its impact among Alaska Native people has never been evaluated. We aimed to evaluate changes in obesity-related metrics over time, and determine associations of changes with cardiometabolic markers of chronic disease risk among AN people. METHODS AND RESULTS: Study participants enrolled in the southcentral Alaska Education and Research Towards Health Study in 2004-2006 were invited to participate in a follow-up study conducted 2015-2017. Of the original 1320 participants, 388 completed follow-up health assessments consisting of multiple health surveys, anthropometric measurements, and cardiometabolic measures including blood sugars, blood lipids, and blood pressure. Differences in measurements between visits were determined and associations of weight change with cardiometabolic measures evaluated. Body mass index increased by 3.7 kg/m2 among men and 4.8 kg/m2 among women. Hip circumference (1.1 cm, p < 0.01) and waist circumference (0.7 cm, p < 0.01) increased among women; only waist circumference increased among men (1.6 cm, p < 0.01). Among men, there were no associations of weight change with cardiometabolic measures. Among women, there was an inverse association between weight gain and high-density lipoprotein cholesterol only (0.17 mg/dL (CI: -3.1, -0.03), p = 0.02). CONCLUSIONS: While weight increase over a 10-year period was not associated with substantive changes in cardiometabolic measures among AN men, there was a decrease in high density lipid cholesterol associated with weight gain among AN women.

Increase in diabetes among urban Alaska Native people in the Alaska EARTH follow-up study: A call for prediabetes screening, diagnosis, and referral for intervention.

AIMS: This study estimates incidence of diabetes (DM) and pre-DM relative to DM risk factors among relatively healthy Alaska Native and American Indian (henceforth AN) adults living in urban south central Alaska. METHODS: Baseline (2004-2006) and follow-up (2014-2017) surveys, blood samples, and medical chart review data were collected from AN adults living in south central Alaska. We analyzed associations between prevalent risk factors and incident DM and pre-DM using Cox proportional hazards and used multivariable models to identify independent predictors for both DM and pre-DM. RESULTS: Among 379 participants with follow-up data, overall DM incidence was 16.5/1,000 PY; overall pre-DM incidence was 77.6/1,000 PY, with marked differences between men and women. Prevalent cardiometabolic risk factors also varied with greater amounts of overweight in men and greater amounts of obesity in women. Controlling for age and sex, obesity, abdominal adiposity, pre-DM, and metabolic syndrome independently increased DM risk. CONCLUSION: Health care providers of AN populations must seize the opportunity to screen, refer, and treat individuals with pre-DM and other modifiable DM risk factors prior to DM diagnosis if we are to alter the epidemiologic course of disease progression in this urban AN population.

Incorporating Participant and Clinical Feedback into a Community-Based Participatory Research Study of Colorectal Cancer Among Alaska Native People.

Alaska Native (AN) people have among the highest rates of colorectal cancer (CRC) globally. We are developing a community-based participatory research (CBPR) informed program to understand risk and protective factors contributing to these high rates. In 2018, we conducted a pilot study to test feasibility of recruiting participants from the Alaska Native Medical Center CRC Screening Clinic into a prospective epidemiologic study. Post-pilot study completion, we conducted focus groups (n = 2) with participants and key informant interviews (n = 7) with research and clinical staff to understand study experiences. During 106 days of recruitment, 30 participants enrolled in the pilot study. Over half (60%) were female, and most (67%) were aged 40-59 years. Key themes that emerged from the participant focus groups were: the desire to contribute to improving the health of AN people as a key driver of participation; an overall positive experience with the study; the benefit of clinical staff notifying patients about the study; the need to clearly explain the purpose of each biospecimen collected; barriers to participation; and, the importance of returning study results to the community. Key themes from research and clinical staff interviews included: the study not interfering with clinical duties; the importance of relationships between clinical and research staff; the importance of research staff flexibility; and, comments on specific study procedures. As part of the CBPR process, this feedback will be incorporated into study protocols. We are building this pilot work into a larger prospective study that will inform primary prevention programs.

Alaska Native Traditional Food and Harvesting Activity Patterns over 10 Years of Follow-Up.

BACKGROUND: Alaska Native (AN) traditional foods and associated harvesting activities are beneficial to human health. OBJECTIVE: This study assessed longitudinal self-reported traditional food use and harvesting activities among Alaska Native and American Indian (AN/AI) participants in the Alaska Education and Research Towards Health (EARTH) study. METHODS: In 2004-2006, southcentral Alaska EARTH study participants (n = 1320) completed diet and activity questionnaires which were repeated in 2015-2017; results were compared between participants who completed both questionnaires (n = 388). RESULTS: In the follow-up questionnaire, >93% of participants reported eating ≥1 traditional food in the past year. The top 3 traditional foods were fish (75%), moose (42%), and shellfish (41%). Women were more likely than men to consume traditional foods, especially fish, gathered berries, shellfish, and seal oil (P < 0.05). Participants aged ≥60 y in the original cohort were significantly more likely to consume fish and shellfish at follow-up, whereas those aged 40-59 y were the most likely of the 3 age groups to consume seal oil (P < 0.05). Between the original cohort and follow-up, there was a significant decline in the mean number of traditional foods eaten from 6.3 to 5.5, as well as reduced consumption of multiple traditional foods (P < 0.001). Over 59% of participants reported ≥1 traditional harvesting activity in the past year; this proportion did not significantly change between baseline and follow-up. Picking berries/greens (44%), cutting/smoking fish or meat (33%), and fishing (30%) were the most common activities. Participation in traditional harvesting activities was greater among women than men (P < 0.05), but did not differ by age. CONCLUSIONS: Longitudinal follow-up demonstrated that AN/AI people maintained participation in traditional harvesting activities, but the variety of traditional foods declined significantly among both men and women. Promotion of traditional foods and harvesting activities that serve as protective factors against chronic diseases may benefit this population.

Alaska Native Patient and Provider Perspectives on the Multitarget Stool DNA Test Compared With Colonoscopy for Colorectal Cancer Screening.

Objective: Alaska Native (AN) people have among the world's highest rate of colorectal cancer (CRC). We assessed perceptions of AN people and their health care providers of a new take-home multitarget stool DNA test (MT-sDNA; Cologuard) relative to colonoscopy. Methods: Cross-sectional surveys of AN people aged 40 to 75 years (mailed) and providers (online). Results: Participants included 1616 AN patients (19% response rate) and 87 providers (26% response rate; 57% AN people). Over half (58%) of patients preferred colonoscopy for CRC screening, while 36% preferred MT-sDNA. Unscreened patients were significantly more likely to state a preference for MT-sDNA than previously screened patients (42% vs 31%, P < .05) as were younger patients (<60 years old) compared with older patients (40% vs 30%, P < .05). Most providers thought that MT-sDNA would improve screening rates (69%), would recommend if available (79%), and be implementable (79%). Perceived barriers differed substantially between patients and providers in both type and magnitude. Leading colonoscopy barriers reported by patients were travel (44%) and bowel preparation (40%), while providers thought that fear of pain (92%) and invasiveness of the test (87%) were the primary barriers. For MT-sDNA, patients' belief that colonoscopy was better (56%) and not knowing how to do the test (40%) were primary barriers, while providers thought stool collection (67%) and having a stool sample in their home (63%) were leading barriers. Conclusions: This study found that MT-sDNA has potential acceptability among AN people and their health care providers. Both groups reported a willingness to use MT-sDNA and did not perceive major barriers to its use. This preference was especially true of unscreened and younger patients. The majority of providers indicated they would use MT-sDNA if available and that it would improve CRC screening rates. In this population, where colonoscopy access is limited, MT-sDNA has the potential to improve CRC screening adherence.

Developing an Epidemiologic Study to Investigate Risk Factors for Colorectal Cancer Among Alaska Native People.

Alaska Native (AN) people have among the highest rates of colorectal cancer (CRC) recorded globally. Preventing CRC is an important health priority of AN tribal health leaders and communities. Lifestyle and genetic risk and protective factors for CRC among AN people remain understudied. We have been working to establish a tribally led, community-based, comprehensive investigation of lifestyle and genetic risk and protective factors for CRC among AN people. We describe the process of initiating this research study, including conversations with key tribal health system staff. We discuss themes that arose during these conversations and literature review and describe how those themes were used during the study design and protocol development phase. This description is intended to provide guidance to other researchers working to establish community-based studies of cancer risk, particularly among tribal communities.

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

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

Improving the Health of Alaska Native People Through Use of a Policy Change Model and Capacity Building.

Public health training often includes program and education development but not policy, systems, and environmental (PSE) strategies. The Alaska Native Tribal Health Consortium's Good Health and Wellness in Indian Country program works to build tribal PSE change capacity. Trainings included community health assessment, facilitation and leadership engagement, policy and systems, and digital storytelling. From 2014 to 2017, 30 PSE changes were made: 3 tobacco-free healthcare organization policies; 2 tobacco-free tribal resolutions; 1 tobacco-free school district policy; 3 healthy food policies and environmental changes; 4 improvements in patient-provider communication; 13 prediabetes, obesity, and/or tobacco screening and referral policies; 3 improvements to health care facility signage; and 1 Baby-friendly Hospital application, protecting the health of 46,000 tribal community members. Targeted training and technical assistance moved tribal staff from a focus on direct services to population-based improvements. This increased self-efficacy may increase the sustainability of chronic disease public health efforts and improve tribal health.

Follow-up Study Methods for a Longitudinal Cohort of Alaska Native and American Indian People Living within Urban South Central Alaska: The EARTH Study.

Longitudinal data are needed to investigate chronic disease causation and improve prevention efforts for Alaska Native and American Indian (ANAI) people. This paper describes the methods used to conduct follow-up data collection of a longitudinal cohort that enrolled ANAI adults between 2004 and 2006 in south central Alaska. The follow-up study re-examined ANAI participants in a large, urban centre in south central Alaska between 2015 and 2017. Computerized surveys were used to collect self-reported health, lifestyle, physical activity, and diet data. Clinical measurements included blood pressure, fasting blood glucose and lipid panel, urine albumin/creatinine, height, weight, and waist and hip circumference. Participants were provided individual results at the conclusion of their visit. A total of 1320 south central Alaska study participants completed the baseline visit. Study staff attempted to contact all living cohort members for inclusion in the follow-up study. More than 11,000 attempted contacts were made. Of the 637 available for participation, 388 completed the follow-up visit. The proportion of women increased from baseline to follow-up examinations (67 vs. 72%, p < 0.01). Self-reported health status of being married or living as married (46% vs. 39%, p < 0.01), and those reporting being employed or self-employed (55% vs. 47%, p < 0.01) were higher at follow-up when compared to baseline. Almost all participants at follow-up (97%) agreed to long-term storage of biological specimens for future study. Despite demographic differences between the follow-up and baseline cohorts, longitudinal data collected will provide novel insight on chronic disease development and prevention for ANAI people as well as other populations.

Determinants of tuberculosis trends in six Indigenous populations of the USA, Canada, and Greenland from 1960 to 2014: a population-based study.

BACKGROUND: Tuberculosis continues to disproportionately affect many Indigenous populations in the USA, Canada, and Greenland. We aimed to investigate whether population-based tuberculosis-specific interventions or changes in general health and socioeconomic indicators, or a combination of these factors, were associated with changes in tuberculosis incidence in these Indigenous populations. METHODS: For this population-based study we examined annual tuberculosis notification rates between 1960 and 2014 in six Indigenous populations of the USA, Canada, and Greenland (Inuit [Greenland], American Indian and Alaska Native [Alaska, USA], First Nations [Alberta, Canada], Cree of Eeyou Istchee [Quebec, Canada], Inuit of Nunavik [Quebec, Canada], and Inuit of Nunavut [Canada]), as well as the general population of Canada. We used mixed-model linear regression to estimate the association of these rates with population-wide interventions of bacillus Calmette-Guérin (BCG) vaccination of infants, radiographic screening, or testing and treatment for latent tuberculosis infection (LTBI), and with other health and socioeconomic indicators including life expectancy, infant mortality, diabetes, obesity, smoking, alcohol use, crowded housing, employment, education, and health expenditures. FINDINGS: Tuberculosis notification rates declined rapidly in all six Indigenous populations between 1960 and 1980, with continued decline in Indigenous populations in Alberta, Alaska, and Eeyou Istchee thereafter but recrudescence in Inuit populations of Nunavut, Nunavik, and Greenland. Annual percentage reductions in tuberculosis incidence were significantly associated with two tuberculosis control interventions, relative to no intervention, and after adjustment for infant mortality and smoking: BCG vaccination (-11%, 95% CI -6 to -17) and LTBI screening and treatment (-10%, -3 to -18). Adjusted associations were not significant for chest radiographic screening (-1%, 95% CI -7 to 5). Declining tuberculosis notification rates were significantly associated with increased life expectancy (-37·8 [95% CI -41·7 to -33·9] fewer cases per 100 000 for each 1-year increase) and decreased infant mortality (-9·0 [-9·5 to -8·6] fewer cases per 100 000 for each death averted per 1000 livebirths) in all six Indigenous populations, but no significant associations were observed for other health and socioeconomic indicators examined. INTERPRETATION: Population-based BCG vaccination of infants and LTBI screening and treatment were associated with significant decreases in tuberculosis notification rates in these Indigenous populations. These interventions should be reinforced in populations still affected by tuberculosis, while also addressing the persistent health and socioeconomic disparities. FUNDING: Public Health Department of the Cree Board of Health and Social Services of James Bay.