Alaska Native Adults Research Articles

Cultural and demographic correlates of dual tobacco use in a sample of Alaska Native adults who smoke cigarettes.

INTRODUCTIONApproximately 9 million American adults use two or more tobacco products regularly, referred to as dual or poly tobacco users. In Alaska, where tobacco is not native, approximately 20% of the population smokes cigarettes, and among smokers, 10% use two or more tobacco products. Previous research suggests that dual tobacco product use may be especially high among Alaska Native people. The current study examined cultural and demographic characteristics associated with dual tobacco use.METHODSAlaska Native adults reporting daily smoking and identified with high blood pressure or cholesterol were recruited in the Norton Sound region of Alaska between 2015–2019 as part of a treatment trial targeting cardiovascular disease risk factors. Participants reported their tribal group, level of identification with their Alaska Native heritage, speaking of their tribal language, basic demographic characteristics, and past 30-day use of tobacco products in addition to smoking cigarettes.RESULTSParticipants (n=299) were 48.5% female and identified as Yup’ik (31.1%), Inupiat (60.5%), and other or multiple tribal group(s) (8.4%). Most participants (85.3%) strongly identified with their Alaska Native heritage. Past 30-day dual tobacco use was reported by 10.0%, specifically 9.0% chew/snuff, 1.3% e-cigarettes, and 0.7% Iq’mik. Multivariate regression models indicated that dual tobacco use was more likely among men (OR=3.35; 95% CI: 1.30–8.64), younger participants (OR range: 10.97–12.35; 95% CI: 2.33–57.86), those identifying as Yup’ik (OR=2.86; 95% CI: 1.13–7.19), and those who identified very little or not at all with their Alaska Native heritage (OR=2.98; 95% CI: 1.14–7.77).CONCLUSIONSYoung men identifying as Yup’ik were more likely to use dual forms of tobacco. Stronger identification with one’s Alaska Native heritage was associated with lower risk of dual tobacco use. The findings highlight cultural and demographic factors for further consideration and attention in tobacco cessation treatment interventions.

Mo1676 COST EFFECTIVENESS OF MULTI-TARGET STOOL DNA TEST VERSUS COLONOSCOPY OR FECAL IMMUNOCHEMICAL TEST FOR COLORECTAL CANCER SCREENING AMONG ALASKA NATIVE PEOPLE

Alaska Native people have higher incidence and mortality from colorectal cancer (CRC) and lower CRC screening rates than U.S. whites. Alaska’s large and predominately roadless geography presents CRC screening challenges, particularly for endoscopy. The objective of this study was to estimate the cost-effectiveness of the multi-target stool DNA test (MT-sDNA) compared with colonoscopy and fecal immunochemical test (FIT) for Alaska Native people. A Markov model was used to evaluate effects of three CRC screening strategies for Alaska Native adults aged 40-75: colonoscopy every 10 years, annual FIT, or MT-sDNA testing every three years, over a 40-year period. An Alaska Native health-system perspective and Alaska Native-specific and national data were updated from previous models to incorporate new evidence on test performance; probabilistic sensitivity analyses explored perfect and imperfect screening adherence. The main outcome measures were CRC incidence and mortality; cost; quality-adjusted life years (QALYs); and incremental cost-effectiveness ratio (ICER). With perfect adherence, CRC incidence was reduced by 51.7% (95% CI: 46.3%-55.9%) using colonoscopy, 60.7% (95% CI: 56.5%-64.2%) using annual FIT, and 65.7% (95% CI: 62.9%-68.3%) using MT-sDNA. Compared with no screening, perfect adherence screening extends life by 0.15 QALYs per person with colonoscopy, 0.17 QALYs per person with FIT, and 0.19 QALYs per person with MT-sDNA. Screening by colonoscopy at ten-year intervals is the most expensive strategy, about $110M more than MT-sDNA and $127M more than FIT. With imperfect adherence (best case), MT-sDNA resulted in 0.12 QALYs/person vs. 0.05 QALYS/person by FIT and 0.06 QALYS/person by colonoscopy. Probabilistic sensitivity analyses supported the findings of the base-case analysis. Under perfect and imperfect adherence scenarios, MT-sDNA either dominates or is cost-effective (ICERs range from $1,740 to $75,868 per QALY saved) as compared with FIT and colonoscopy. Each strategy reduced costs and increased QALYs in comparison with no screening. Screening by MT-sDNA results in the largest savings of QALYs, in all adherence scenarios. In a Markov model analysis, we found that screening by MT-sDNA in the Alaska Native population is cost-effective as compared to screening by colonoscopy and FIT, for a wide range of adherence scenarios.

Association of Resilience and Stress with Health Behaviors Among American Indian and Alaska Native Adults

Abstract Objectives Literature suggests stress and resilience (i.e., perceived ability to cope with stress) are associated with health behaviors. American Indian and Alaska Native (AIAN) adults have increased risk for stress due to historical trauma, discrimination, and higher odds of living in poverty. Despite this, they have not been included in prior quantitative investigations of the association of stress and resilience with health behaviors. The objectives of this work are to describe resilience and stress levels of AIANs and evaluate the associations of resilience and stress with diet and physical activity. Methods Cross-sectional surveys were collected from adults who self-identified as AIAN at three pow wows that took place in Oklahoma and Washington state in 2018. Surveys included: Cohen's 10-item Perceived Stress Scale that ranges from 0–40 in which higher scores indicate higher stress; the Brief Resilience Scale with scores that range from 1–5 and higher scores indicative of higher resilience; one item on quality of eating habits (10-point scale from ‘poor’ to ‘excellent’); two items estimating hours of sedentary activities; and two items estimating hours of physical activity. T-tests and chi-squared tests assessed bivariate differences in health behaviors by high or low stress and resilience, based on scoring above or below the median. Results The mean age of 636 respondents was 45.6 years and 62% identified as female. The median score was 16 for stress was 16 and 3.5 for resilience. High self-reported stress was associated with lower perceived diet quality (5.3 vs. 5.7; P = 0.02). Respondents reporting higher stress levels also reported engaging in more hours of sedentary behaviors on the weekend (P < 0.001). In contrast, high resilience was related to fewer hours of sedentary activities during weekdays and weekends (both P = 0.04). Stress and resilience were not related to moderate or vigorous physical activity. Conclusions Compared with prior studies, AIAN adults in this study reported high levels of both stress and resilience. This cross-sectional study further supports a possible relationship between health behaviors, stress, and resilience. Future investigations should account for other factors related to stress and health behaviors, such as age, income, education, and living situation. Funding Sources N/A.

Respiratory syncytial virus and influenza hospitalizations in Alaska native adults

BackgroundAlaska Native (AN) infants from Yukon Kuskokwim Delta (YKD) have the highest U.S. infant hospitalization rate for respiratory syncytial virus (RSV). RSV can cause significant morbidity and mortality in adult populations, although the RSV burden in AN adults is unknown. Here we investigate RSV, influenza, and human metapneumovirus (hMPV) in hospitalized rural AN adults. MethodsYKD AN adults, hospitalized with acute respiratory illness between November 2016 and October 2018 were enrolled prospectively. Nasopharyngeal (NP) swabs were tested for RSV, influenza and hMPV using polymerase chain reaction. Hospitalization rates were calculated. ResultsOf 251 patients who had an NP swab, RSV was detected in 8 (3.2 %), influenza in 31 (12.4 %), and hMPV in no patients. Weighted annual rates of lower respiratory tract infection (LRTI), RSV and influenza hospitalization were 192.0 (95 % CI: 176.5–208.4), 9.1 (6.0−13.3), and 42.2 (35.1−50.2) per 10,000. The most common discharge diagnosis was pneumonia (57.0 %), followed by chronic obstructive pulmonary disease (51.4 %). Ninety-eight percent (246/251) had a medical co-morbidity and 49.8 % (125/251) lived in a house with a smoker. Overall, 6.4 % (16/251) required mechanical ventilation, and 3.6 % (9/251) died during hospitalization. Only 35.7 % (66/185) of patients admitted during influenza season had received the annual influenza vaccine. DiscussionWe examined adult LRTI, influenza, and RSV hospitalization rates in an AN population with high infant RSV hospitalization rates. While we confirmed a high rate of hospitalization from LRTIs and influenza, we did not find a high rate due to RSV or hMPV. Improving influenza vaccination rates, and addressing co-morbidities could reduce respiratory hospitalizations.

Prevalence of diagnosed diabetes in American Indian and Alaska Native adults, 2006–2017

IntroductionThe objective of this study was to examine recent trends in diagnosed diabetes prevalence for American Indian and Alaska Native (AI/AN) adults aged 18 years and older in the Indian...

Recruitment best practices of a cardiovascular risk reduction randomised control trial in rural Alaska Native communities

ABSTRACT Though not native to Alaska, tobacco use is common among Alaska Native people in the Norton Sound region, an area consisting of 16 communities with population size 107 to 3,695. We summarise best practices in recruiting Alaska Native adults who smoke for a randomised controlled tobacco treatment trial. Participants were Alaska Native, 19 years and older, smoking daily, with hypertension and/or high cholesterol, residing in the Norton Sound region of Alaska. Study staff travelled to the remote communities to recruit, typically staying 5 days. Screening and enrolment success was examined by day, season, and staffing level. From June 2015 – December 2018, the study team made 122 trips, screening 1089 individuals and enrolling 314 participants. In the field, days 2–3 (51%) were best for screening, while days 3–4 (53%) had the greatest enrolment. Community size correlated with enrolment (r = 0.83, p <.001). Recruitment was optimised in spring and with multiple staff in the field. Despite challenges (e.g., harsh weather, poor internet connectivity), with active outreach (e.g. tabling in busy areas, attending community events, utilising mixed media, collaborating with clinic staff), the project reached its recruitment goal. Study findings can inform community-based tobacco treatment research trials in remote areas. Abbreviations CVD: Cardiovascular disease; VTC: Video teleconferencing; ANMC: Alaska Native Medical Centre; HEALTHH: Healing and Empowering Alaskan Lives Towards Healthy Hearts; NSHC: Norton Sound Health Corporation; RERB: Research Ethics Review Board

Adult outcomes of childhood bronchiectasis

ABSTRACT Recent literature has highlighted the importance of transition from paediatric to adult care for children with chronic conditions. Non-cystic fibrosis bronchiectasis is an important cause of respiratory morbidity in low-income countries and in indigenous children from affluent countries; however, there is little information about adult outcomes of childhood bronchiectasis. We reviewed the clinical course of 31 Alaska Native adults 20–40 years of age from Alaska’s Yukon Kuskokwim Delta with childhood bronchiectasis. In patients with chronic suppurative lung disease, a diagnosis of bronchiectasis was made at a median age of 4.5 years by computerised tomography (68%), bronchogram (26%), and radiographs (6%). The patients had a median of 75 lifetime respiratory ambulatory visits and 4.5 hospitalisations. As children, 6 (19%) experienced developmental delay; as adults 9 (29%) experienced mental illness or handicap. Four (13%) patients were deceased, four (13%) had severe pulmonary impairment in adulthood, 17 (54%) had persistent or intermittent respiratory symptoms, and seven (23%) were asymptomatic. In adulthood, only five were seen by adult pulmonologists and most had no documentation of a bronchiectasis diagnosis. Lack of provider continuity, remote location and co-morbidities can contribute to increased adult morbidity. Improving the transition to adult care starting in adolescence and educating adult providers may improve care of adults with childhood bronchiectasis.

Health care utilisation changes among Alaska Native adults after participation in an indigenous community programme to address adverse life experiences: a propensity score-matched analysis

ABSTRACT The aim of this study was to investigate whether participation in Family Wellness Warriors Initiative (FWWI), an Alaska Native program that addresses adverse life experiences, is associated with changes in health care utilisation. The study method was a propensity score-matched cohort analysis using retrospective electronic health record data from Southcentral Foundation, a tribal health care system, from 2012 to 2017. Ninety p\\articipants in FWWI trainings were identified as the intervention cohort and were propensity matched with 90 people who participated in other emotional wellness-related interventions. The primary outcome was the number of total health system visits. Secondary outcomes included emergency department (ED) visits, substance-use visits and visits with somatisation potential. After adjustment for covariates, FWWI participants showed a 36% reduction in total system visits (incidence rate ratio 0.64, 95% CI 0.49–0.84) and a 70% reduction in substance use visits (incidence rate ratio 0.30, 95% CI 0.10–0.93) when compared to the control. FWWI participants showed a 40% reduction in ED visits (incidence rate ratio 0.60, 95%CI 0.35–1.02) when compared to the control that was borderline significant. No significant differences were found for visits with somatisation potential (incidence rate ratio 1.25, 95% CI 0.79–1.99).

LINKAGES BETWEEN INDIGENOUS CULTURAL GENERATIVITY AND SOBRIETY TO PROMOTE ALASKA NATIVE SUCCESSFUL AGING

The aim of this study was to explore motivating and maintenance factors for sobriety among older AN adult participants (age 50+) from across Alaska. Ten life history narratives of Alaska Native older adults, representing Alutiiq, Athabascan, Tlingit, Yup’ik/Cup’ik Eskimos, from the PA sample were explored using thematic analysis. AN older adults are motivated to abstain from, or to quit drinking alcohol through spirituality, family influence, role socialization and others’ role modeling, and a desire to engage in indigenous cultural generative activities with their family and community. A desire to pass on their accumulated wisdom to a younger generation through engagement and sharing of culturally grounded activities and values, or indigenous cultural generativity, is a central unifying motivational and maintenance factor for sobriety. The implications of this research indicate that family, role expectations and socialization, desire for community and culture engagement, and spirituality are central features to both AN Elders’ understanding of sobriety and more broadly, to their successful aging. Future research is needed to test these findings in population-based studies and to explore incorpo- ration of these findings into alcohol treatment programs to support older AN adults’ desire to quit drinking and attain long-term sobriety. Sobriety can put older AN adults on a pathway to successful aging, in positions to serve as role models for their family and community, where they are provided opportunities to engage in meaningful indigenous cultural generative acts.

Protective Effects of Educational Attainment Against Cigarette Smoking; Diminished Returns of American Indians and Alaska Natives in the National Health Interview Survey.

Although educational attainment is protective against health risk behaviors such as smoking, Minorities' Diminished Returns theory posits that these protective effects are smaller for ethnic minority than the majority groups. compare the effects of educational attainment on smoking status of American Indian Alaska Native (AIAN) and White adults. Data came from the National Health Interview Survey (NHIS - 2015). A total number of 21114 individuals entered our analysis. The independent variable was years of schooling. The dependent variable was current smoking status. Age, gender, region, marital status, and employment were covariates. Ethnicity was the moderator. Overall, educational attainment was inversely associated with current smoking. Ethnicity showed a significant interaction with educational attainment that was suggestive that the protective effects of educational attainment against smoking is smaller for AIAN than Whites. In the United States, while educational attainment helps individuals stay healthy by avoiding high risk behaviors such as smoking, this effect is smaller for AIANs than Whites. The result is additional risk of smoking in highly educated AIANs. To reduce ethnic disparities I tobacco use, it is important to go beyond SES inequalities and investigate why high SES ethnic minorities remain at high risk of tobacco use.

Regional Differences In Coverage Among American Indians And Alaska Natives Before And After The ACA.

Understanding regional variation in the effect of the Affordable Care Act (ACA) on health insurance coverage among vulnerable populations such as American Indian and Alaska Native adults has important policy implications. We used American Community Survey data for the period 2010-17 to examine unadjusted trends in health insurance coverage among American Indians and Alaska Natives across ten US regions. In each region we also used multivariate regression to evaluate the effects of the ACA on insurance coverage among American Indians and Alaska Natives and differences in effects between that group and non-Hispanic whites. In the West we observed significant improvements in public insurance among American Indians and Alaska Natives, and disparities compared to non-Hispanic whites were reduced following the ACA. Although there were unadjusted increases in insurance coverage across most regions, regression analyses suggested that there were no significant post-ACA changes in public or private health insurance coverage among American Indians and Alaska Natives in the Oklahoma, Bemidji, or Alaska regions. In sum, health insurance among American Indians and Alaska Natives increased after the ACA, but improvements were not consistent across regions. More attention is needed to improve insurance coverage among American Indians and Alaska Natives in midwestern regions.

Understanding the Economic Costs of Diabetes and Prediabetes and What We May Learn About Reducing the Health and Economic Burden of These Conditions.

Over 30 million people suffered from diabetes in 2015, representing 9.4% of the entire U.S. population and 12.2% of all adults (1). One in four of these people did not know they had diabetes (1). Furthermore, in the same year, approximately 84.1 million U.S. adults—over a third of U.S. adults (33.9%)—were believed to have prediabetes, 90% of whom were also unaware of their condition (1). The high prevalence of gestational diabetes mellitus (GDM) (6.0%) among women who gave birth in 2016 further underscores the seriousness of this epidemic (2). The burden of diabetes is not uniformly shared, varying by age, education, income, location, race/ethnicity, and other social determinants of health (SDOH) (1–6). Greater burden is evident among adults with lower educational attainment and household income than among adults of higher socioeconomic status (1,3), disparities that have widened over time (3). In 2015, compared with non-Hispanic whites (7.4%), the age-adjusted prevalence of diagnosed diabetes was higher among American Indian and Alaska Native adults (15.1%), non-Hispanic black adults (12.7%), adults of Hispanic ethnicity (12.1%), and Asian adults (8.0%) (1). The prevalence of undiagnosed diabetes (4,5), prediabetes (7), and GDM (2,6) also varied by SDOH. Federal, state, and local governments—ultimately, taxpayers—bear the brunt of diabetes-related costs. For example, Medicare’s diabetes-related burden increased during recent years as the prevalence of diabetes increased (8). Updated, comprehensive information on the economic burden of diabetes-related conditions is critical for governments, employers, other health payers, and health care providers to assess opportunities for improving service delivery and, ultimately, health outcomes. Dall et al. (9) updated and expanded the American Diabetes …

663-P: Online Diabetes Nutrition Education for American Indian and Alaska Native Adults with Type 2 Diabetes: Stakeholder Perspectives

Nutrition education is known to promote healthful dietary behaviors and reduce diet-related complications among people with diabetes. American Indians and Alaska Natives (AIAN) have more than double the risk for type 2 diabetes (T2D) and diabetes-related complications than non-Hispanic whites. Despite the high prevalence of T2D in AIAN communities, AIANs often lack access to diabetes-related nutrition education, particularly resources targeted to AIAN audiences. Literature suggests that online nutrition education may effectively serve low-income audiences, but research specific to AIANs is scarce. We employed qualitative focus group and individual interview methods to understand stakeholder perspectives on the feasibility of an online eLearning diabetes nutrition education program for AIAN adults with T2D. We interviewed four types of stakeholders, including: experts in AIAN diabetes nutrition education (n=9); AIAN educators, Native elders, and tribal leaders (n=11); and AIAN adults with T2D (n=29) and their family members (n=22) at 4 geographically distinct urban and reservation sites. Focus groups and interviews were recorded and transcribed verbatim. The constant comparison method guided data coding and thematic analysis and Atlas.ti (Mac Version 8.0) was used to digitalize the analysis. Participants shared that smartphone-based Internet access is common among AIAN adults, except for the very old. Sixty percent of focus group participants indicated that they use the Internet at least daily. Participants reported interest in online education opportunities that are reputable, culturally adapted for AIAN people, and smartphone friendly. Educators and leaders indicated that access to a registered dietitian and food resource management education via online learning would provide Native people with the additional support needed to eat healthfully in communities with high rates of food insecurity and limited access to healthy food. Disclosure S.A. Stotz: None. A.G. Brega: None. K.R. Moore: None. Funding American Diabetes Association (4-18-SMSC-01 to K.R.M.)

662-P: Facilitators and Barriers to Healthy Eating among American Indian/Alaska Native Adults with Type 2 Diabetes: Stakeholder Perspectives

American Indian and Alaska Native (AIAN) adults have a higher rate of type 2 diabetes (T2D) and related complications than non-AIAN adults. Nutrition is the cornerstone of diabetes self-management and nutrition education is a key component of diabetes self-management education. The purpose of this research was to understand stakeholder perspectives on how to adapt the American Diabetes Association (ADA) newly developed nutrition education program entitled “What Can I Eat? Choices for People with T2D and their Families” (WCIE) for AIAN adults. Using focus group and individual interview methods, we interviewed experts in AIAN diabetes nutrition education (n=9); AIAN educators, Native elders, and tribal leaders (n=11); and AIAN adults with T2D (n=29) and their family members (n=22) at 4 geographically distinct urban and reservation sites nationwide. Focus groups and interviews were recorded and transcribed verbatim. We employed the constant comparison method for data analysis and used Atlas.ti (Mac version 8.0) to digitalize the analytical process. Qualitative analysis identified specific facilitators and barriers to healthy eating in Native communities. Facilitators included: strong community and family support systems, traditional values of balance and gratitude, Native pride, and community-based wellness goals. Barriers included: food insecurity, challenges to preparation of home-cooked meals, high consumption of fast food and sugar-sweetened beverages, and loss of access to traditional foods and food-acquisition practices. Findings will be used to culturally adapt the existing ADA WCIE diabetes nutrition education program for AIAN adults with T2D. Disclosure K.R. Moore: None. S.A. Stotz: None. A.G. Brega: None. K.L. Gonzales: None. Funding American Diabetes Association (4-18-SMSC-01 to K.R.M.)

Depression management interests among Alaska Native and American Indian adults in primary care

BackgroundDepression remains the second leading cause of disability worldwide. Symptoms of depression are expressed and experienced differently across cultural groups, impacting treatment decisions. Patient preferences predict service utilization, treatment selection and persistence, as well as health outcomes for medical and behavioral health conditions, including depression. We identified depression management preferences of Alaska Native and American Indian (AN/AI) people who receive care within a comprehensive, integrated, tribally owned and operated healthcare facility in Anchorage, Alaska. MethodsAdult AN/AI patients who screened positive for depression (10 or greater on the Patient Health Questionnaire – 9 (PHQ-9)) completed a culturally-tailored decision-support tool to assess their depression management interests. ResultsThe 125 eligible patients, who screened positive for depression, preferred counseling and medications to peer support groups, herbal remedies, and spiritual support. Those 18–39 years of age were more likely to prefer medications and less likely to prefer spirituality and peer support than those 40 years of age and older. Patients with moderate and severe depression were more likely to prefer exercise, healthy eating, and stress reduction than individuals with mild depression. LimitationsWomen comprised 78% of the sample. Responses may not adequately represent the views of men. ConclusionsCounseling and medications should consistently be made available earlier in the course of depression management. Patient interest in exercise, stress reduction, and healthy eating to manage depression, especially among those with moderate and severe depression, offers opportunity for additional collaboration in an integrated care setting.

Mental health burden in a national sample of American Indian and Alaska Native adults: differences between multiple-race and single-race subgroups.

Research on American Indian and Alaska Native (AIAN) mental health disparities is based largely on either tribal populations or national samples of adults that do not account for multiracial AIANs, even though over 40% of AIANs identify with multiple racial groups. The present investigation extends this research by assessing mental health status in a national sample of multiracial AIAN adults relative to adults who identify exclusively as either AIAN or White. 2012 BRFSS data were used to conduct multinomial logistic regression analyses comparing mental health outcomes among respondents who identified as either AIAN and one or more other races (AIAN-MR), AIAN-Single Race (AIAN-SR), or White-SR. After demographic adjustment, the AIAN-MR group reported a higher lifetime prevalence of diagnosed depressive disorder, more days of poor mental health, and more frequent mental distress compared to both the AIAN-SR and White-SR groups. AIAN-MR individuals also had higher levels of Kessler 6 (K6) non-specific psychological distress compared to White-SR individuals but not AIAN-SR adults. Differences between AIAN-SR and White-SR adults were found in days of poor mental health, frequent mental distress, and total K6 scores. These findings help gauge the magnitude of mental health disparities in the U.S. AIAN population and pinpoint AIAN subgroups for whom mental health is particularly problematic. As such, they raise concerns about restrictions that limit the identification of national survey respondents who report multiple race designations. Such restrictions will thwart efforts to understand the causal mechanisms and pathways leading to mental distress among AIAN individuals.

251 - Risk and Protective Factors for Hypertension in American Indian and Alaska Native Adolescents and Adults: A Systematic Review

251 - Risk and Protective Factors for Hypertension in American Indian and Alaska Native Adolescents and Adults: A Systematic Review

Prevalence of Mixed Connective Tissue Disease in a Population-Based Registry of American Indian/Alaska Native People in 2007.

To determine the prevalence of mixed connective tissue disease (MCTD) in 2007 in the Indian Health Service (IHS) active clinical population from 3 regions of the US. The IHS Lupus Registry was designed to identify possible MCTD cases in addition to systemic lupus erythematosus cases. The population denominator for this report includes American Indian or Alaska Native adults within the IHS active clinical population in 2007, residing in select communities in 3 regions of the US. Potential MCTD cases were identified using a broad range of diagnostic codes and were confirmed by detailed medical record abstraction. Classification as MCTD for this analysis required both rheumatologist diagnosis of MCTD without diagnosis of other CTD, and documentation of the Alarcón-Segovia MCTD criteria in the medical record. Prevalence was also calculated using 2 alternate definitions of MCTD. The age-adjusted prevalence of MCTD using our primary definition was 6.4 per 100,000 (95% confidence interval 2.8-12.8). The prevalence was higher in women than in men using all 3 definitions of MCTD, and no men met the criteria for the primary definition of MCTD. The first population-based estimates of the prevalence of MCTD in the US American Indian/Alaska Native population show that the prevalence appears to be higher than in other populations. Additional population-based estimates are needed to better understand the epidemiology of MCTD.

Alaska Native Elders in Recovery: Linkages between Indigenous Cultural Generativity and Sobriety to Promote Successful Aging.

This article builds on the People Awakening (PA) Project, which explored an Alaska Native (AN) understanding of the recovery process from alcohol use disorder and sobriety. The aim of this study is to explore motivating and maintenance factors for sobriety among older AN adult participants (age 50+) from across Alaska. Ten life history narratives of Alaska Native older adults, representing Alutiiq, Athabascan, Tlingit, Yup'ik/Cup'ik Eskimos, from the PA sample were explored using thematic analysis. AN older adults are motivated to abstain from, or to quit drinking alcohol through spirituality, family influence, role socialization and others' role modeling, and a desire to engage in indigenous culturalgenerative activities with their family and community. A desire to pass on their accumulated wisdom to a younger generation through engagement and sharing of culturally grounded activities and values, or indigenous cultural generativity, is a central unifying motivational and maintenance factor for sobriety. The implications of this research indicates that family, role expectations and socialization, desire for community and culture engagement, and spirituality are central features to both AN Elders' understanding of sobriety, and more broadly, to their successful aging. Future research is needed to test these findings in population-based studies and to explore incorporation of these findings into alcohol treatment programs to support older AN adults' desire to quit drinking and attain long-term sobriety. Sobriety can put older AN adults on a pathway to successful aging, in positions to serve as role models for their family and community, where they are provided opportunities to engage in meaningful indigenous cultural generative acts.

Application of the PEN-3 Model to Tobacco Initiation, Use, and Cessation Among American Indian and Alaska Native Adults.

American Indian (AI) and Alaska Native (AN) communities confront some of the highest rates of tobacco use and its sequelae. As part of a formative research project investigating stakeholder understandings, preferences, and needs surrounding the use of pharmacogenetics toward tobacco cessation treatment, we sought to characterize sociocultural issues related to tobacco use and cessation. We used the PEN-3 cultural model to frame the research question and analysis of stakeholder interviews with 20 AI/AN patients, 12 health care providers, and 9 tribal leaders. Our study found high knowledge levels of the negative health effects of tobacco use; however, most patient participants ascribed negative health effects only to regular, heavy tobacco use and not to light use, which is more common in the population. The majority of patient participants did not endorse use of tobacco cessation treatment despite evidence of efficacy among AI/AN adults. Health promotion messaging to target low-tobacco consuming AI/AN people is needed. Additionally, messaging to promote tobacco cessation treatment using successful AI/AN former tobacco users to improve community perception of tobacco cessation treatment is recommended.