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

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

Testing a Culturally Adapted Colorectal Cancer Screening Decision Aid Among American Indians: Results from a Pre-Post Trial.

Purpose: American Indian adults have not experienced decreases in colorectal cancer (CRC) incidence and mortality observed in other races or ethnic groups and their screening rates are low. Decision aids that explain available CRC screening options are one potential strategy to promote screening. The goal of this study was to test the effect of a culturally adapted decision aid on CRC-related outcomes among American Indian adults, including screening-related knowledge, attitudes, self-efficacy, intentions, and screening modality preferences. Methods: We recruited American Indian adults aged 50-75 years who were not current with CRC screening. Participants viewed a 9-min multimedia decision aid that used narrative vignettes to provide educational information about screening along with messages to address culturally specific barriers and values uncovered in formative research. We conducted a single-arm (pre-post) study and assessed screening-related outcomes at baseline and immediately after viewing the decision aid. Results: Among n=104 participants, knowledge scores increased from a mean of 36% correct to 76% correct. Participants also had statistically significant increases in positive attitudes, perceived social norms, self-efficacy, and intent. The proportion of participants who identified a preference for a specific CRC screening modality rose from 81% identified at pre-intervention to 93% post-intervention (p=0.013). Conclusion: Our study provides promising new findings that our culturally adapted decision aid is efficacious in educating American Indian adults about CRC screening and increases their screening intentions and ability to state modality preferences. Future research is needed to test the decision aid as a component of CRC screening interventions with American Indian adults.

Perspectives of American Indians in Eastern North Carolina on Socio-cultural Factors that Influence Colorectal Cancer Screening Decisions.

American Indians (AI) have disproportionately high rates of colorectal cancer (CRC), but there is relatively little research focused on developing AI CRC screening interventions. We held six focus groups with AIs in rural Eastern U.S. (n=74) and analyzed the qualitative data from them in order to identify individual and socio-cultural factors that influence AI CRC screening decisions. Screening fear and anxiety was a central theme of the focus groups. For example, participants told stories about how late-stage cancer diagnoses and deaths in the community contributed to their fears and cancer fatalism. Furthermore, CRC screening fears were reinforced by health communication norms that limited productive conversations about CRC screening. Our findings indicate that culturally adapted interventions, such as CRC screening decision aids, are needed to help AIs communicate and make informed decisions about CRC screening with support from family and health care providers. More research is needed on the influence of these interventions on CRC screening intentions, social norms, and shared decision-making.

Community Advisory Boards Guiding Engaged Research Efforts within a Clinical Translational Sciences Award: Key Contextual Factors Explored.

BACKGROUND: Engaging stakeholders in research carries the promise of enhancing the research relevance, transparency, and speed of getting findings into practice. By describing the context and functional aspects of stakeholder groups, like those working as community advisory boards (CABs), others can learn from these experiences and operationalize their own CABs. Our objective is to describe our experiences with diverse CABs affiliated with our community engagement group within our institution's Clinical Translational Sciences Award (CTSA). We identify key contextual elements that are important to administering CABs. METHODS: A group of investigators, staff, and community members engaged in a 6-month collaboration to describe their experiences of working with six research CABs. We identified the key contextual domains that illustrate how CABS are developed and sustained. Two lead authors, with experience with CABs and identifying contextual domains in other work, led a team of 13 through the process. Additionally, we devised a list of key tips to consider when devising CABs. RESULTS: The final domains include (1) aligned missions among stakeholders (2) resources/support, (3) defined operational processes/shared power, (4) well-described member roles, and (5) understanding and mitigating challenges. The tips are a set of actions that support the domains. CONCLUSIONS: Identifying key contextual domains was relatively easy, despite differences in the respective CAB's condition of focus, overall mission, or patient demographics represented. By contextualizing these five domains, other research and community partners can take an informed approach to move forward with CAB planning and engaged research.

Comparing 3 values clarification methods for colorectal cancer screening decision-making: a randomized trial in the US and Australia.

PURPOSE: To compare the effects of three methods of values clarification (VCM): balance sheet; rating and ranking; and a discrete choice experiment (DCE) on decision-making about colorectal cancer (CRC) screening among adults in the US and Australia. METHODS: Using online panels managed by a survey research organization in the US and Australia, we recruited adults ages 50-75 at average risk for CRC for an online survey. Those eligible were randomized to one of the three VCM tasks. CRC screening options were described in terms of five key attributes: reduction in risk of CRC incidence and mortality; nature of the screening test; screening frequency; complications from screening; and chance of requiring a colonoscopy (as initial or follow-up testing). Main outcomes included self-reported most important attribute and unlabeled screening test preference by VCM and by country, assessed after the VCM. RESULTS: A total of 920 participants were enrolled; 51 % were Australian; mean age was 59.0; 87.0 % were white; 34.2 % had a 4-year college degree; 42.8 % had household incomes less than $45,000 USD per year; 44.9 % were up to date with CRC screening. Most important attribute differed across VCM groups: the rating and ranking group was more likely to choose risk reduction as most important attribute (69.8 %) than the balance sheet group (54.7 %) or DCE (49.3 %), p < 0.0001; most important attribute did not vary by country (p = 0.236). The fecal occult blood test (FOBT)-like test was the most frequently preferred test overall (55.9 %). Unlabeled test choice did not differ meaningfully by VCM. Australians were more likely to prefer the FOBT (AU 66.2 % vs. US 45.1 %, OR 2.4, 95 % CI 1.8, 3.1). Few participants favored no screening (US: 9.2 %, AU: 6.2 %). CONCLUSIONS: Screening test attribute importance varied by VCM, but not by country. FOBT was more commonly preferred by Australians than by Americans, but test preferences were heterogeneous in both countries.