Pre-Pandemic and Recent Oral and Medical Health Care Utilization among Young American Indian Children and Their Caregivers.

Children from diverse ethnic groups are at significantly increased risk for dental caries. In particular, American Indian (AI) children have the highest incidence of detal caries of any ethnic group. The COVID-19 pandemic dramatically restricted health care access, including preventive oral health care. Given this context, it is unclear whether or not preventive oral health care for AI children has resumed since lockdown. To address this question, we surveyed adult AI caregivers (N = 152) of children aged 0-5 years, assessing recent (12-month) and pre-COVID (for caregivers of children aged 3-5 years) preventive oral and medical health services. We also examined medical health care access and utilization among caregivers. Among children aged 3-5 years old, both pre-pandemic and past year medical care utilization were generally high (80 and 90%, respectively) as was any oral health care utilization (64 & 78%, respectively). Oral health check-ups were more common over the last year (62%) compared to pre-COVID (44%). Recent health care utilization among children 1-5 years old in this sample were generally comparable to national estimates, except for higher reported preventive medical care (99% vs. 87.6%, respectively) and higher preventive oral care (96% vs. 59.6%, respectively). More caregivers reported delaying or foregoing needed health care due to COVID (28-38%) versus due to cost (8-17%). In this survey of AI caregivers, recent child preventive health care utilization was high, and changes in utilization following the lockdown phases of the pandemic were comparable for oral and medical health care.

Intertribal Talking Circle for the prevention of alcohol and drug use among Native American youth.

The purpose of this study was to examine the impact of a culturally based intervention, the Intertribal Talking Circle program, compared to a standard alcohol and drug abuse education, the Be A Winner program. Community-based participatory research was used to implement a two-condition, quasi-experimental study. The sample included 540 Native American youth ages 10-12 years old from three tribal areas in the United States. Data were collected at baseline, 6 and 12-months post-intervention for both the intervention and control groups using demographic, cultural identity, alcohol use, and drug use questionnaires. Regression models evaluated participants' improvement in decreasing alcohol and drug use and increasing cultural identity. Findings revealed that alcohol and drug use decreased more significantly among youth who participated in the Intertribal Talking Circle (ITC) intervention program than youth who participated in a standard alcohol and drug abuse education Be A Winner (BAW) program. Cultural identity also increased more significantly among participants who completed the Talking Circle intervention program. Native American youth ages 10-12 years old respond positively to a culturally based intervention for the reduction of alcohol and drug use. The findings highlight the importance of cultural values and identity and their significance in preventing and reducing alcohol and drug use among Native American youth.

Baseline results from NenUnkUmbi/EdaHiYedo: A randomized clinical trial to improve sexual and reproductive health among American Indian adolescents.

We report on baseline findings from NenUnkUmbi/EdaHiYedo, a community based participatory research randomized controlled trial with American Indian adolescents to reduce sexual and reproductive health disparities. American Indian adolescents aged 13-19 years participated in a baseline survey that was administered in five schools. We used zero-inflated negative binomial regression to evaluate how the count of protected sexual acts was associated with independent variables of interest. We stratified models by self-reported gender of adolescents and tested for a two-way interaction effect between gender and the independent variable of interest. Two hundred twenty-three girls and 222 boys (n = 445) were sampled. The average number of lifetime partners was 1.0 (standard deviation = 1.7). Each additional lifetime partner was associated with a 50% increase in the number of protected sexual acts incident rate ratio (IRR = 1.5, 95% confidence interval [CI] 1.1-1.9) and more than a twofold increase in the likelihood of not having protected sexual acts (adjusted odd ratio [aOR] = 2.6, 95% CI 1.3-5.1). Each additional number of substances used in adolescentss' lifetime was associated with an increased likelihood of not having protected sexual acts (aOR = 1.2, 95% CI 1.0-1.5). In boys, each one standard deviation increase in depression severity was associated with a 50% reduction in the number of times a condom was used adjusted IRR (aIRR = 0.5, 95% CI 0.4-0.6, p < .001). Each 1-unit increase in positive prospections of pregnancy was associated with a pronounced decrease likelihood of not having protected sexual acts (aOR = 0.01, 95% CI 0.0-0.1). Findings support the importance of tribally driven tailoring of sexual and reproducive health interventions and services for American Indian adolescents.

Examining the role of race and quality of home health agencies in delayed initiation of home health services for individuals with Alzheimer's disease and related dementias (ADRD).

INTRODUCTION: We examined differences in the timeliness of the initiation of home health care by race and the quality of home health agencies (HHA) among patients with Alzheimer's disease and related dementias (ADRD). METHODS: Medicare claims and home health assessment data were used for the study cohort: individuals aged ≥65 years with ADRD, and discharged from the hospital. Home health latency was defined as patients receiving home health care after 2 days following hospital discharge. RESULTS: Of 251,887 patients with ADRD, 57% received home health within 2 days following hospital discharge. Black patients were significantly more likely to experience home health latency (odds ratio [OR] = 1.15, 95% confidence interval [CI] = 1.11-1.19) compared to White patients. Home health latency was significantly higher for Black patients in low-rating HHA (OR = 1.29, 95% CI = 1.22-1.37) compared to White patients in high-rating HHA. DISCUSSION: Black patients are more likely to experience a delay in home health care initiation than White patients.

Home health services for minorities in urban and rural areas with Alzheimer's and related dementia.

Timely access and continuum of care in older adults with Alzheimer's Disease and Related Dementia (ADRD) is critical. This is a retrospective study on Medicare fee-for-service beneficiaries with ADRD diagnosis discharged to home with home health care following an episode of acute hospitalization. Our sample included 262,525 patients. White patients in rural areas have significantly higher odds of delay (odds ratio [OR], 1.03; 95% CI, 1.01-1.06). Black patients in urban areas (OR, 1.15; 95% CI, 1.12-1.19) and Hispanic patients in urban areas also were more likely to have a delay (OR, 1.07; 95% CI, 1.03-1.11). Black and Hispanic patients residing in urban areas had a higher likelihood of delay in home healthcare initiation following hospitalization compared to Whites residing in urban areas.

Health outcomes and healthcare utilization of Native Hawaiians and other Pacific Islanders living with HIV in Hawai'i: A mixed-methods study.

OBJECTIVES: Past research shows mixed outcomes in terms of HIV-related disparities among Native Hawaiians and Pacific Islanders (NHOPI). This study investigates HIV-related disparities among NHOPI living with HIV in Hawai'i. DESIGN: An explanatory sequential design was utilized. The quantitative portion analyzed survey data from a statewide Ryan White Needs Assessment (N = 398) to examine the differences in viral suppression and satisfaction with care between NHOPI and other ethnic groups. Utilizing the behavioral model for vulnerable populations (BMVP), semi-structured interviews (N = 16) were conducted next to explain what factors play a role in satisfaction with care and viral suppression when it comes to NHOPI living with HIV in Hawai'i. RESULTS: Among the 398 participants 13% were NHOPI. NHOPI were more likely to have a viral load of ≥10,000 copies/mL compared to those who didn't identify as NHOPI. However, there were no significant differences for other viral load levels (20-199 or 200-9999), and only 20 participants (5.2%) had a viral load of 10,000 copies/mL or more. No significant ethnic differences were found in satisfaction with medical care. In the qualitative phase, factors from all domains of the BMVP were represented within the four themes identified: (1) Care coordination is essential- with AIDs service organizations taking the lead; (2) HIV care, as well as overall health, is defined by the effectiveness of medication; (3) Initial diagnosis is a critical moment for intervention; and (4) Aspects of culture are intangible. CONCLUSION: Among NHOPI in Hawai'i who are engaged in case management, there appears to be no substantial disparities in either viral load or satisfaction with care compared to other ethnic groups. Despite this, qualitative findings provide insights on how ethnicity and culture may still be playing a role. Addressing all domains of the BMVP is crucial to addressing this.

"Cancer is in style": lifestyle change and the perceived impact of globalization on Andean indigenous communities in Ecuador.

Introduction: There is a paucity of information on cancer among Indigenous populations in Latin America.Methods: Guided by tenets of community engaged research and syndemic theory, we conducted eight focus groups (n = 59) with Kichwa men and women in the province of Imbabura, Ecuador. Data were analyzed using applied thematic analysis techniques.Results: Cancer emerged as an important health problem and was reported as a growing concern. Kichwa participants in this study attributed the rise in cancer to (1) exposure to chemicals and pesticides, (2) urbanization and development, and (3) the rise of innutritious, westernized diets.Conclusion: Our findings suggest that the Kichwa are attuned to the global phenomena in which traditional diet has been replaced by western, processed foods and fast food, which result in higher levels of chronic diseases such as cancer. More research is needed to understand the cancer burden among Indigenous peoples in Latin America.

The Role of State Medicaid Expansions in Integrating Comprehensive Mental Health Services into Opioid Treatment Programs: Differences Across the Rural/Urban Continuum.

Co-occurring mental health (MH) problems are common among those with opioid use disorders (OUDs). However, most opioid treatment programs (OTPs) do not provide MH services. We measured the association between state level characteristics (Medicaid expansion status and rurality) and MH/OUD services integration. We used a generalized linear model to estimate how the association between integration and Medicaid expansions varied across levels of rurality (National Survey on Substance Abuse Treatment Services; 2018; n = 1507 OTPs). The predicted probability of OTPs offering MH services decreased as rurality increased, and the strength of the negative association was greater in non-expansion states ([Formula: see text]=-0.038, SE = 0.005, p < 0.0001) than in expansion states ([Formula: see text]=-0.020, SE = 0.003, p < 0.0001). Access to integrated MH services was lowest in rural non-Medicaid expansion states, despite the high risk of opioid misuse and a high need for MAT and MH services in this population.

Formative Research and Cultural Tailoring of a Substance Abuse Prevention Program for American Indian Youth: Findings From the Intertribal Talking Circle Intervention.

Background. Substance use among American Indians (AIs) is a critical health issue and accounts for many health problems such as chronic liver disease, cirrhosis, behavioral health conditions, homicide, suicide, and motor vehicle accidents. In 2013, the highest rates of substance use and dependence were seen among AIs when compared to all other population groups, although these rates vary across different tribes. Among AI adolescents, high rates of substance use have been associated with environmental and historical factors, including poverty, historical trauma, bicultural stress, and changing tribal/familial roles. Our project, the Intertribal Talking Circle intervention, involved adapting, tailoring, implementing, and evaluating an existing intervention for AI youth of three tribal communities in the United States. Formative Results. Community partnership committees (CPCs) identified alcohol, marijuana, and prescription medications as high priority substances. CPC concerns focused on the increasing substance use in their communities and the corresponding negative impacts on families, stating a lack of coping skills, positive role models, and hope for the future as concerns for youth. Cultural Tailoring Process Results. Each site formed a CPC that culturally tailored the intervention for their tribal community. This included translating Keetoowah-Cherokee language, cultural practices, and symbolism into the local tribal customs for relevance. The CPCs were essential for incorporating local context and perceived concerns around AI adolescent substance use. These results may be helpful to other tribal communities developing/implementing substance use prevention interventions for AI youth. It is critical that Indigenous cultures and local context be factored into such programs.

Opportunities for and Perceptions of Integrating Community Health Workers Via the Affordable Care Act: Medicaid Health Homes.

CONTEXT: The Affordable Care Act created opportunities for innovative, cost-saving measures to improve health care access. Community health workers (CHWs) are frontline public health workers who have a close understanding of the communities they serve. States that expanded Medicaid coverage could also create Medicaid Health Homes (MHHs)-virtual health care networks-to coordinate care for people with chronic conditions. New York was the second state to implement MHHs and gave the option to include CHWs as part of the health care team. OBJECTIVE: To understand the perceptions of MHH administrators regarding CHW engagement in MHHs, as well as the facilitators and barriers to adoption in MHHs that are unknown. DESIGN, SETTING, AND PARTICIPANTS: Semistructured qualitative interviews (n = 18) were conducted with MHH administrators throughout New York State guided by the Diffusion of Innovations (DOI) framework. Qualitative thematic analysis was used to explore the domains and themes. RESULTS: Most MHH administrators believed that CHWs fit within MHHs. The DOI constructs of compatibility and complexity and the Consolidated Framework for Implementation Research construct of external policies helped explain CHW integration. CHWs were compatible with MHHs by enrolling patients, helping coordinate patient care, and providing social support. The complexities of CHW integration into MHHs included barriers to CHW integration, no direct reimbursement for their services, lack of clarity for CHW roles and responsibilities, and no explicit external policy for their use in MHHs. CONCLUSIONS: CHWs can, and have, been integrated into the relatively novel Health Home system. While some barriers have prevented their integration into all MHHs, lessons learned could provide guidance for CHW integration into other health care systems in the United States.

Post-earthquake Self-Reported Depressive Symptoms and Post-Traumatic Stress Disorder and their Correlates among College-Youths in Kathmandu, Nepal.

Exposure to earthquake has previously been associated with adverse mental health outcomes, however, evidence is limited among youth in resource-limited settings. This study explored the association of retrospective extent of exposure on current day depressive symptoms and post-traumatic stress disorder (PTSD) symptoms among 125 youth attending a college in Kathmandu, Nepal. A self-administered survey including socio-demographic variables, scale for earthquake exposure and Nepali language validated standardized scales for depressive and PTSD symptoms was used. Prevalence estimates for depressive symptoms was 43.2% and PTSD symptoms was 19.2%. For each increasing unit of the extent of earthquake exposure, the odds of having depressive symptoms increased by a factor of 1.26 (p = 0.001) and PTSD symptoms increased by a factor of 1.26 (p = 0.002). Being in a complicated romantic relationship increased the odds of both depressive symptoms and PTSD symptoms. Exposure to earthquake is an important factor to consider while assessing depressive and PTSD symptoms among youth earthquake survivors in Kathmandu. It is important that programs or policies aimed at youth mental health concurrently address disaster exposures.

US trends in mask wearing during the COVID-19 pandemic depend on rurality.

INTRODUCTION: Face masks are widely recommended as a COVID-19 prevention strategy. State mask mandates have generally reduced the spread of the disease, but decisions to wear a mask depend on many factors. Recent increases in case rates in rural areas following initial outbreaks in more densely populated areas highlight the need to focus on prevention and education. Messaging about disease risk has faced challenges in rural areas in the past. While surges in cases within some communities are likely an impetus for behavior change, rising case rates likely explain only part of mask-wearing decisions. The current study examined the relationship between county-level indicators of rurality and mask wearing in the USA. METHODS: National data from the New York Times' COVID-19 cross-sectional mask survey was used to identify the percentage of a county's residents who reported always/frequently wearing a mask (2-14 July 2020). The New York Times' COVID-19 data repository was used to calculate county-level daily case rates for the 2 weeks preceding the mask survey (15 June - 1 July 2020), and defined county rurality using the Index of Relative Rurality (n=3103 counties). Multivariate linear regression was used to predict mask wearing across levels of rurality. The model was adjusted for daily case rates and other relevant county-level confounders, including county-level indicators of age, race/ethnicity, gender, political partisanship, income inequality, and whether each county was subject to a statewide mask mandate. RESULTS: Large clusters of counties with high rurality and low mask wearing were observed in the Midwest, upper Midwest, and mountainous West. Holding daily case rates and other county characteristics constant, the predicted probability of wearing a mask decreased significantly as counties became more rural (β=-0.560; p<0.0001). CONCLUSION: Upticks in COVID-19 cases and deaths in rural areas are expected to continue, and localized outbreaks will likely occur indefinitely. The present findings highlight the need to better understand the mechanisms underlying perceptions of COVID-19 risk in rural areas. Dissemination of scientifically correct and consistent information is critical during national emergencies.

Racial/Ethnic Differences in Drug- and Alcohol-Related Arrest Outcomes in a Southwest County From 2009 to 2018.

Objectives. To estimate the association between race/ethnicity and drug- and alcohol-related arrest outcomes.Methods. We used multinomial logistic regression and general estimating equations to estimate the association between race/ethnicity and arrest outcomes in 36 073 drug- and alcohol-related arrests obtained from administrative records in a Southwest US county from 2009 to 2018. Results were stratified by charge type.Results. Among misdemeanor drug- and alcohol-related arrests, American Indian/Alaska Native (AI/AN; adjusted odds ratio [AOR] = 3.60; 95% confidence interval [CI] = 3.32, 3.90), Latino (AOR = 1.53; 95% CI = 1.35, 1.73), and Black persons (AOR = 1.28; 95% CI = 1.05, 1.55) were more likely than White persons to be booked into jail as opposed to cited and released. AI/AN (AOR = 10.77; 95% CI = 9.40, 12.35), Latino (AOR = 2.63; 95% CI = 2.12, 3.28), and Black persons (AOR = 1.84; 95% CI = 1.19, 2.84) also were more likely than White persons to be convicted and serve time for their misdemeanor charges. Results were similar for felony drug- and alcohol-related arrests aggregated and stratified.Conclusions. Our results suggest that race/ethnicity is associated with outcomes in drug-related arrests and that overrepresentation of racial/ethnic minorities in the criminal justice system cannot be attributed to greater use of drugs and alcohol in general.

Social Determinants of Potential eHealth Engagement Among People Living with HIV Receiving Ryan White Case Management: Health Equity Implications from Project TECH.

OBJECTIVES: Evaluate the relationships between social characteristics of Floridian persons living with HIV (PLWH) and both use of digital technologies and willingness to use eHealth for HIV-related information. METHODS: Ryan White case managers (N = 155) from 55 agencies in 47 Florida counties administered a survey to PLWH (N = 1268) from June 2016-April 2017. Multilevel logistic regression models were used to identify correlates of technology use and willingness. RESULTS: Use of mobile phones with text messaging was high (89%). Older (vs. younger) adults and non-Hispanic blacks (vs. whites) were less likely to use most technologies. These groups, along with Hispanics (vs. whites) were less likely to express willingness to use technologies for HIV-related information in models adjusting for use. CONCLUSIONS: Among PLWH in Florida, eHealth-related inequities exist. Willingness to engage in HIV-related eHealth is affected by social determinants, even when considering technology access. Although eHealth may reduce some healthcare inequities, it may exacerbate others.

Young adult US-born Latina women's thoughts, feelings and beliefs about unintended pregnancy.

Current measures of unintended pregnancy underestimate the co-occurring, complex set of social, cultural, economic and structural factors that influence how women interpret unintended pregnancy. The purpose of this study was to prospectively explore young adult US-born Latinas' thoughts, feelings and beliefs about pregnancy, specifically unintended pregnancies and the sociocultural factors identified as contributors to those beliefs. In-depth interviews (n = 20) were conducted with US-born, English-speaking Latinas aged 18-25 years in south Florida. Seventeen participants did not intend to get pregnant, while the remaining participants (n = 3) reported that their intentions kept changing. Participants' beliefs regarding their unintended pregnancy were influenced by social and economic hardship and cultural factors such as fatalism and familismo. Ideas and the meaning of pregnancy differed based on the woman's pregnancy resolution decision. Many women felt the term 'unintended pregnancy' placed blame on women and was stigmatising. When discussing pregnancy planning, most participants felt that women should not plan their pregnancies and doing so was going against fate. Findings suggest that salient influences such as culture and the social determinants related to unintended pregnancy should be incorporated into measurements examining unintended pregnancy.

Encompassing Cultural Contexts Within Scientific Research Methodologies in the Development of Health Promotion Interventions.

American Indians/Alaska Natives/Native Hawaiians (AI/AN/NHs) disproportionately experience higher rates of various health conditions. Developing culturally centered interventions targeting health conditions is a strategy to decrease the burden of health conditions among this population. This study analyzes characteristics from 21 studies currently funded under the Interventions for Health Promotion and Disease Prevention in Native American (NA) Populations program among investigators currently funded under this grant mechanism. Four broad challenges were revealed as critical to address when scientifically establishing culturally centered interventions for Native populations. These challenges were (a) their ability to harness culture-centered knowledge and perspectives from communities; (b) their utilization of Indigenous-based theories and knowledge systems with Western-based intervention paradigms and theories; (c) their use of Western-based methodologies; and (d) their cultural adaptation, if based on an evidence-based treatment. Findings revealed that qualitative methodologies and community-based participatory research (CBPR) approaches were very commonly used to finalize the development of interventions. Various Indigenous-based theories and knowledge systems and Western-based theories were used in the methodologies employed. Cultural adaptations were made that often used formative mixed qualitative and quantitative methods. Illustrative examples of strategies used and suggestions for future research are provided. Findings underscored the importance of CBPR methods to improve the efficacy of interventions for AI/AN/NH communities by integrating Indigenous-based theories and knowledge systems with Western science approaches to improve health.

Growing from Our Roots: Strategies for Developing Culturally Grounded Health Promotion Interventions in American Indian, Alaska Native, and Native Hawaiian Communities.

Given the paucity of empirically based health promotion interventions designed by and for American Indian, Alaska Native, and Native Hawaiian (i.e., Native) communities, researchers and partnering communities have had to rely on the adaptation of evidence-based interventions (EBIs) designed for non-Native populations, a decidedly sub-optimal approach. Native communities have called for development of Indigenous health promotion programs in which their cultural worldviews and protocols are prioritized in the design, development, testing, and implementation. There is limited information regarding how Native communities and scholars have successfully collaborated to design and implement culturally based prevention efforts "from the ground up." Drawing on five diverse community-based Native health intervention studies, we describe strategies for designing and implementing culturally grounded models of health promotion developed in partnership with Native communities. Additionally, we highlight indigenist worldviews and protocols that undergird Native health interventions with an emphasis on the incorporation of (1) original instructions, (2) relational restoration, (3) narrative-[em]bodied transformation, and (4) indigenist community-based participatory research (ICBPR) processes. Finally, we demonstrate how culturally grounded interventions can improve population health when they prioritize local Indigenous knowledge and health-positive messages for individual to multi-level community interventions.

Exploring health and wellness among Native American adults with intellectual and/or developmental disabilities and their family caregivers.

BACKGROUND: Adults with intellectual and/or developmental disabilities (IDD) experience health inequities, and those who also identify as a member of an ethnic minority group face additional health inequities. In the United States, a majority of adults with IDD continue to be supported by family caregivers making their health equity also important. The purpose of this study was to explore how Native American adults with IDD and their family caregivers experience health and wellness. METHOD: This community-engaged research was guided by a Community Advisory Board (CAB) with study participants completing a Photovoice project. RESULTS: Participants identified individual, family and community level influences on health and wellness including the importance of participation in meaningful activities and connection to culture. CONCLUSIONS: In order to address health inequities, more research is needed to understand health and wellness from the unique perspectives of individuals with IDD and those from racial and ethnic minority groups.

Epidemiology of Incarceration: Characterizing Jail Incarceration for Public Health Research.

BACKGROUND: Each year, 9 million individuals cycle in and out of jails. The under-characterization of incarceration as an exposure poses substantial challenges to understanding how varying levels of exposure to jail may affect health. Thus, we characterized levels of jail incarceration including recidivism, number of incarcerations, total and average number of days incarcerated, and time to reincarceration. METHODS: We created a cohort of 75,203 individuals incarcerated at the Coconino County Detention Facility in Flagstaff, Arizona, from 2001 to 2018 from jail intake and release records. RESULTS: The median number of incarcerations during the study period was one (interquartile range [IQR] = 1-2). Forty percent of individuals had >1 incarceration. The median length of stay for first observed incarcerations was 1 day (IQR = 0-5). The median total days incarcerated was 3 (IQR = 1-23). Average length of stay increased by number of incarcerations. By 18 months, 27% of our sample had been reincarcerated. CONCLUSION: Characteristics of jail incarceration have been largely left out of public health research. A better understanding of jail incarcerations can help design analyses to assess health outcomes of individuals incarcerated in jail. Our study is an early step in shaping an understanding of jail incarceration as an exposure for future epidemiologic research. See video abstract at, http://links.lww.com/EDE/B536.

Towards an Information Motivation and Behavioral Skills Model for New Sex Partners: Results of a Study of Condom Use as an HIV Prevention Method for Emerging Adults Who Met Partners on Dating and Sex-Seeking Platforms or Offline.

The information, motivation, behavioral Skills (IMB) model was used to identify factors that affect condom use with new sex partners that were met offline or online. Mixed methods data were collected from adults between the ages of 18 and 29 years who reported a new sex partner. A model was composed of participants' IMB scale scores to determine the effect of these variables on condom use. A subset of 20 survey participants completed interviews exploring how IMB model elements may have influenced their condom use. Mixed methods results showed condom use skills were influential for condom use during the first sexual encounter between new partners. Qualitative findings suggest the information and motivation may also influence condom use with new sex partners. The IMB model for new partners may be relevant model for the development of interventions that encourage emerging adults to use condoms at first sex with new sex partners.