Choctaw Nation Research Articles

Abstract B046: Factors influencing patient decision-making to complete Low Dose CT screening for lung cancer

Abstract As part of a randomized, controlled trial (RCT) to increase lung cancer screening (LCS) with low-dose CT scan (LDCT) within the Choctaw Nation of Oklahoma’s tribal health system, we conducted a qualitative study to explore the barriers behind patient decisions to forego screening. Thirty eligible participants who had been in the RCT for at least one year were identified as LCS completers (n=7) or non-completers (n=23). A single interviewer completed all interviews using a semi-structured interview guide, designed to explore experiences, barriers/facilitators to LCS, factors influencing screening decisions, and suggested strategies for expanding the LCS program into the community. Interviews were recorded and transcribed verbatim. Data were analyzed using conventional content analysis. Most non-completers reported having no conversations about the availability of LCS with their primary care provider (PCP) or receiving any information about the LCS program. In contrast, the completers all reported PCP-initiated discussions about the LCS program, their risk factors, and an overview of the testing process. Key themes that emerged included fears, e.g., being unsure about what the test involves, afraid of being diagnosed with lung cancer and what might follow, and afraid of dying. Some voiced concerns, e.g., feeling guilty as active smokers and being stigmatized should they be diagnosed with lung cancer. Many participants posited that there was no reason for screening without symptoms. Lack of understanding, especially about cancer care, was identified as a contributing factor. Suggested strategies to increase the reach into the community included using existing infrastructure within Choctaw Nation, such as disseminating information through the tribal newsletter, inserts in prescription refills, and notifications via the patient portal. Community education programs at local community centers, particularly around senior citizen meals, were offered as strategies to change the perception that lung cancer is a death sentence. Hosting an informational booth at the annual tribal Labor Day festival was commonly suggested. In conclusion, multiple reasons were cited for forgoing LDCT screening. In this tribal setting, findings are similar to ones documented in other settings. This suggests that interventions to overcome these challenges may build off known evidence-based interventions, such as the recommendations for cancer prevention documented by the Community Preventive Services Task Force. Addressing fears through multiple educational approaches and adapting strategies from the American Lung Association to address stigma could lead to enhanced interventions. Finally, capitalizing on tribal resources (newsletter) and tribal events to increase LCS awareness may be promising strategies to improve screening in the local tribal setting. Citation Format: Kathleen Dwyer, Zsolt Nagykaldi, Mark Doescher, Dorothy A. Rhoades. Factors influencing patient decision-making to complete Low Dose CT screening for lung cancer [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr B046.

Abstract A148: Perceptions of lung cancer screening among Native American patients: The Tribally Engaged Approaches to Lung Screening (TEALS) study

Abstract Introduction: Uptake of lung cancer screening (LCS) with low dose computed tomography is poor nationwide. The U.S. Native American (NA) population has a high prevalence of smoking and lung cancer mortality but low rates of LCS completion. Awareness and perceptions of LCS among NA men and women have rarely been studied. Methods: Using a community-engaged research approach in partnership with the Choctaw Nation Health Services Authority in Oklahoma, the “Tribally Engaged Approaches to Lung Screening” study developed and implemented a cluster-randomized controlled trial of a coordinated LCS program. In 2022, NA men and women eligible for LCS from six tribal health clinics completed a baseline survey prior to being referred for LCS. Surveys included demographic characteristics, smoking history, use of cancer preventive services, beliefs regarding personal risk of lung cancer, and perceptions toward LCS. Findings: Among 210 participants (57% women, 43% men), mean age was 63 years; 50% reported annual household income below $25,000, 83% completed high school or equivalent, with 40% having some college education. The median pack years of smoking was 46 years. The proportion of participants who currently smoke was 72%. Current cigarette users were slightly younger than former users (median age 61 vs 64 years, respectively) and similarly had lower maximum estimates of pack-years of use (median, 44 vs 52). Most (93%) had more than one primary care visit within the past 12 months, and 76% completed an annual physical or wellness visit in the past year. Overall, 73% had completed colonoscopy and, among women, 80% had a mammogram. Only 62% had heard about LCS. However, 74% agreed with the statement “It is likely that I will get lung cancer sometime in my lifetime”. More than 90% of participants agreed that LCS would help with each of the following: early detection, chances of dying from lung cancer, reduce personal worry about lung cancer, reduce their family’s worries, improve planning for the future and peace of mind. However, 44% worried that LCS would find “something wrong”, 15% endorsed that they would rather not know if they had any lung problems, and 10% were afraid the scan would damage their lungs. About 20% worried about being a social outcast or being blamed for having smoked. Regarding potential barriers, 32% felt that cost would be a problem, 28% felt they did not have the time, and 17% that transportation would be a problem. Overall,14% reported bad experiences with healthcare or a provider, and 8% did not trust the healthcare system. Regarding LCS, 28% felt they did not know enough about the test, 11% felt they were too old to benefit from LCS, and 8% felt LCS was not worth the effort. Conclusions: Perceptions of the potential benefits from LCS were overall favorable in this sample of NA adults. However, up to 30% perceived significant barriers to LCS uptake. Greater awareness of LCS and mitigation of barriers to LCS would help to reduce the marked disparities in lung cancer mortality among NA patients. Citation Format: Dorothy A. Rhoades, Cara Vaught, Ann Chou, Kathleen Dwyer, Mark P Doescher, Michele Gibson, Zsolt Nagykaldi. Perceptions of lung cancer screening among Native American patients: The Tribally Engaged Approaches to Lung Screening (TEALS) study [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A148.

Medication Engagement, Determinants of Health, and A1C Levels Among Adults With Type 2 Diabetes within a Tribal Health System.

The purpose of this study was to examine the association between determinants of health, medication engagement, and A1C levels in adults with type 2 diabetes (T2DM) receiving Tribal health and pharmacy services. A retrospective analysis of 2020-2021 electronic health record data was conducted and included adult patients with T2DM using Choctaw Nation Health Services Authority prescribed ≥1 noninsulin glucose-lowering medication in 2020, had ≥1 A1C value in 2020 and 2021, and had a valid zip code in 2021. Patients receiving both insulin and other noninsulin glucose-lowering medication were included. The proportion of days covered (PDC) was used to calculate medication engagement. Statistical analyses included bivariate analysis and linear regression. There were 3787 patients included in the analyses; 62.5% were considered engaged (PDC ≥ 0.8). The mean 2020 A1C level was 8.0 (64 mmol/mol) ± 1.8; 33% had an A1C of <7%, 42% had an A1C of 7% to 9%, and 25% had an A1C >9%. The mean A1C in 2021 was 7.9 (63 mmol/mol) ± 1.7; 34% had an A1C of <7%, 44% had an A1C of 7% to 9%, and 22% had an A1C >9%. Older age was weakly correlated with higher engagement; higher engagement was associated with lower A1C levels while adjusting for covariates. Medication engagement was associated with lower A1C levels, and older age was weakly associated with higher engagement to noninsulin glucose-lowering medications, consistent with previous literature. No determinants of health were significantly associated with A1C levels while adjusting for covariates.

APOE ε4 Allele Frequency Among Cognitively Healthy Members of an Ojibwe Tribal Nation.

APOE ε4 frequency varies by geography and ancestry. We provide data regarding the frequency of this allele in the Ojibwe people, the fifth largest Indigenous people in the United States. Population study including 33 cognitively normal older individuals of an Ojibwe Tribal Nation (total population: 984; all with ≥25% Ojibwe ancestry). APOE ε4 allele frequency was 19.7%, which is comparable with other cognitively normal American Indian, Alaskan Native, and non-Hispanic White populations of the United States and Europe, with the exception of a lower frequency among Choctaw Nation of Oklahoma participants with >50% American Indian ancestry. While some global populations have very low APOE ε4 prevalence, this allele appears common among American Indian Tribal Nations included thus far in the United States. Because APOE ε4 is a cornerstone for novel diagnostics and therapeutics for Alzheimer disease (AD), future study is warranted to understand ancestry-dependent effects of APOE ε4 on AD risk and biology.

No Stone Unturned

A prefatory note from the editorial collective. When the Society for Cultural Anthropology selected our distributed, international editorial collective to lead Cultural Anthropology, they did so in part to support our commitment to opening channels of this crucial platform of our discipline beyond the scope of privileged, endowed higher educational institutions in the United States. As one step of this process, in this issue we provide space to the Choctaw Nation of Oklahoma to describe their work since the passage of the Native American Graves Protection and Repatriation Act (NAGPRA) in 1990. As Deanna L. Byrd, the NAGPRA Liaison-Coordinator and Research and Outreach Program Manager of the Choctaw Nation of Oklahoma, and Ian Thompson, the Tribal Historic Preservation Officer of the Choctaw Nation of Oklahoma, writes, since that time, “Native American communities gained a measure of say in how ancestral burials are treated on federal lands. The law also established a mechanism to help Native American, Alaskan, and Native Hawaiian communities have open dialogue with institutions across the country about the return of their ancestors, funerary objects, sacred objects, and objects of cultural patrimony.” Please read the rest of their guest commentary to learn more.

Circumventing "Hostipitality": The Enduring Legacy of 19th-Century Choctaw Nation and Irish Solidarity

Abstract: The abiding legacy between the Choctaw Nation and Irish citizens stems from a small act of kindness in the 19th century. Following their forced migration during the 1830s, aptly remembered as the Trail of Tears, the Choctaw Nation donated $710 in 1847 ($26,468.37 in 2023 currency) to address Irish poverty resulting from the potato famine (Howe and Kirwan, xxvii). This act of benevolence established a cultural bond between the two groups—one that still thrives and has expanded to include other participants and recipients of their largesse.

The Choctaw Nation's Growing Hope Program.

The Choctaw Nation of Oklahoma's Historic Preservation Department (HPD) and the Center for Indigenous Health Equity (CIIHE) are partnering to implement and evaluate food sovereignty interventions to better understand the potential impact of such programs on individual and community health. The HPD's Growing Hope Program is a food sovereignty initiative that aims to restore traditional Choctaw gardens, which were once a physical, social, and cultural center of Choctaw life. The program combines heirloom seeds and the stories of their origins, gardening education and technical assistance, cooking classes, and a Choctaw youth internship program to support intergenerational knowledge and the restoration of culture and food security. Since its inception the program has provided Choctaw families with ancestral Choctaw cultivar seeds and provided the technical assistance to support the growing of sustainable, healthy, traditional Choctaw foods.

Choctaw Confederates: The American Civil War in Indian Country. By Fay A. Yarbrough

This is the second major book publication by Rice University history professor Fay Yarbrough. Building upon her earlier work on Cherokee gender, race, and legal history, Yarbrough here explores how Choctaws enslaved African Americans and built a legal framework that denied Black rights and contributed to Choctaw support of the Confederate States during the U.S. Civil War. Yarbrough provides insightful analysis of Choctaw government legislation and constitution writing from before Removal through the Civil War and into the Reconstruction era. This legal history aspect exposes the hardening racial dynamics of the Choctaw Nation leading up to the Civil War (especially against unrelated free Blacks and non-married, unrelated White men), gendered discourses, and efforts to support and strengthen tribal sovereignty. Intermixing of Choctaw and Cherokee sources to illustrate slave life among the Indian nations and to explain the problems with trying to remain neutral during the secession crisis causes some confusion but direct sources on the Choctaws are limited.

Association of Medication Adherence With HbA1c Control Among American Indian Adults With Type 2 Diabetes Using Tribal Health Services.

To examine HbA1c levels and adherence to oral glucose-lowering medications and their association with future HbA1c levels among American Indian adults with type 2 diabetes (T2D) receiving medications at no cost from a tribal health care system. Tribal citizens with T2D who used Choctaw Nation Health Services Authority (CNHSA) and Pharmacies and had HbA1c data during 2017-2018 were included in this study. Medication adherence (proportion of days covered [PDC] ≥0.80) was calculated using 2017 CNHSA electronic health record data. Of the 74,000 tribal citizens living on tribal lands, 4,560 were eligible; 32% had HbA1c at or below target (≤7%), 36% were above target (>7 to ≤9%), and 32% were uncontrolled (>9%) in 2017. The percentage of patients with PDC ≥0.80 was 66% for those using biguanides, 72% for sulfonylureas, 75% for dipeptidyl peptidase 4 inhibitors, and 83% for sodium-glucose cotransporter 2 inhibitors. The proportion of patients with HbA1c at or below target increased slightly from 32% in 2017 to 42% in 2018. Higher average PDC in 2017 was associated with lower HbA1c levels in 2018 (β = -1.143; P < 0.001). Medication adherence was higher than that found in previous studies using self-report methods in American Indian populations, although a smaller proportion of patients had HbA1c at or below target relative to U.S. adults with T2D. Medication adherence was associated with improved HbA1c levels for most oral glucose-lowering medication classes. Future studies of American Indians should use both longitudinal prescription data from both electronic health records and pharmacy refills.

Choctaw Confederates: The American Civil War in Indian Country by Fay A. Yarbrough

Reviewed by: Choctaw Confederates: The American Civil War in Indian Country by Fay A. Yarbrough Nakia D. Parker (bio) Choctaw Confederates: The American Civil War in Indian Country. By Fay A. Yarbrough. ( Chapel Hill: University of North Carolina Press, 2021. Pp. 280. Cloth, $32.95.) Scholars are increasingly examining the Civil War and Reconstruction eras in Indian Territory, and their studies often center the Cherokee. Historian Fay A. Yarbrough contributes to this expanding scholarship with the first book about the Choctaw Nation's involvement in the Civil War. In Choctaw Confederates, Yarbrough argues that there were two primary reasons for avid Choctaw support for the Confederacy: Choctaw leaders believed that the Confederacy offered the best chance of protecting Native sovereignty, and the nation's deep investment in the institution of chattel slavery, coupled with a desire to maintain the anti-Black racial hierarchy inherent in that institution, made siding with the Confederacy a logical choice. Choctaw planters had strong economic ties to white southerners even after expulsion to Indian Territory, and their nation was surrounded by southern states, such as Texas and Arkansas. "The Choctaw experience, then" Yarbrough asserts, "was a southern experience" (6). Chapter 1 provides an overview of the political and social structure of the Choctaws in their southeastern homelands, emphasizing how the threat and later implementation of expulsion by the federal government reshaped traditional practices of kinship, gender relations, and governance. For example, Choctaw leaders created a constitutional government based on that of the United States and reshaped property rights, such as inheritance and marital laws, to favor patriarchal instead of matriarchal family lines. Chapter 2 examines the growth of slavery in the Choctaw Nation in Indian Territory and the importance of the institution to economic recovery after removal and "as a part of the developing racial order" that shaped the decision of Choctaw leaders to side with the Confederacy (47). Yarbrough compares testimonies of the enslaved from [End Page 124] Indian Territory and the southern states to highlight the similarities in labor practices. She also provides an in-depth analysis of the laws created by Choctaw leaders soon after resettlement that circumscribed and surveilled almost every aspect of Black life in the nation. In some instances these laws were more restrictive or passed earlier than slave codes in southern states. At the same time, Yarbrough demonstrates that certain laws reflected the "legacy of traditional kinship affinities" and that "as the Choctaw adopted the practice of racialized slavery, they did so in a manner that preserved Choctaw identity" (65, 48). This is especially apparent in her discussion of a clause requiring people of African descent who had no kinship ties with the Choctaw and Chickasaw to leave or be enslaved for life. Chapter 3 discusses the decision of Choctaw leaders to side with the Confederacy by examining the alliance treaty and the debates between Choctaw leaders over joining the conflict. Unlike the Cherokee Nation, which tried to remain neutral and experienced its own internal civil war, the Choctaw swiftly and unambiguously sided with the seceding states. Chapters 4 and 5 chronicle the experiences and motivations of Choctaw men who enlisted to fight for the Confederate cause. Yarbrough skillfully analyzes the thousands of pages of enlistment records of the First Choctaw and Chickasaw Mounted Rifles to probe motivations for joining the Confederate army, circumstances of enlistment, and patterns of enrollment. To demonstrate early Choctaw enthusiasm for the war, Yarbrough points to the records of 950 men who signed up in June and July 1861, before the Choctaw Nation formally allied with the Confederacy. Serving as soldiers and light horsemen allowed Choctaw men, particularly youth, "a way to claim, or reclaim, their identities as warriors" (173). Thus, Yarbrough asserts, the Civil War reshaped and created alternative expressions of traditional notions of Indigenous masculinity. The concluding chapter details the tensions between the Choctaw government and freedpeople in the nation during Reconstruction. The federal government stipulated land and civil rights for the formerly enslaved in the surrender treaty, which angered Choctaw leaders, who viewed these requirements as usurping Native sovereignty. In addition, the anti-Black sentiment present before the war became even more rampant, as evidenced by Black codes, the banning...

Choctaw Confederates: The American Civil War in Indian Country by Fay A. Yarbrough

Reviewed by: Choctaw Confederates: The American Civil War in Indian Country by Fay A. Yarbrough Christine A. Rizzi Choctaw Confederates: The American Civil War in Indian Country. By Fay A. Yarbrough. (Chapel Hill: University of North Carolina Press, 2021. Pp. [xii], 268. $32.95, ISBN 978-1-4696-6511-5.) Fay A. Yarbrough’s latest book, Choctaw Confederates: The American Civil War in Indian Country, provides a much-needed corrective to scholarship on Native experiences during the Civil War era. Yarbrough’s research does not focus on land loss, military tactics, or outside factors that influenced Native alliances with either the United States or the Confederacy. Rather, this new work highlights the internal debates and decisions that led to the Choctaw Nation’s early and consistent alliance with the Confederate States of America. Informed by sources ranging from military records to Choctaw policy, personal correspondence, and oral histories, Yarbrough’s study compellingly demonstrates that internal demands for the maintenance of slavery and the strengthening of tribal sovereignty drove the nation to support the Confederate war effort in 1861. The book provides important context by opening with two chapters that examine the role of slavery in the Choctaw Nation both before and after removal. Yarbrough demonstrates that, rather than feeling exclusively outside pressure to take on Euro-American ideas about property, race, and enslavement, Choctaws “adopted the practice of racialized slavery . . . in a manner that preserved Choctaw identity,” maintaining certain aspects of their traditional livelihoods while also building bonds with white southerners that they [End Page 149] hoped would insulate the nation from land theft (p. 48). Even after that possibility faded in the wake of removal, the Choctaws strengthened the institution of slavery in order to enshrine their own sovereignty and distinctiveness. According to Yarbrough, Choctaws’ demands for the protection of slavery and sovereignty directly informed their enthusiastic support for the Confederacy. The linchpin of her book is arguably the third chapter, which examines the internal debates within the nation regarding a potential Confederate alliance. Yarbrough’s close examination of Choctaw and Confederate treaty negotiations shows that the decision to form this alliance was far from “a foregone conclusion” (p. 111). Instead, Choctaw leaders saw “that the Confederacy proposed principles that were more in line with Choctaw goals than with federal ones” (p. 91). Yarbrough also shows that “the concrete benefits offered by the Confederate government” proved far more compelling to the Choctaws (p. 112). She demonstrates that ordinary Choctaw men and women enthusiastically supported the alliance, providing martial and material support to the Confederate war effort. Enlistment records, government policies, and personal correspondence suggest that Choctaw men willingly enlisted in the Confederate forces, especially in response to crises that threatened the status quo of slavery and sovereignty. Yarbrough further argues that Choctaw men were able to preserve traditional ideas about masculinity through their service in the war effort. The book closes with a chapter examining Reconstruction in Indian Country, comparing and contrasting the Choctaw experience with that of the larger postwar South. While the Choctaws similarly resisted efforts to incorporate freedpeople into the body politic, freedpeople within the nation had more immediate access to land than did their counterparts in the former Confederate states. According to Yarbrough, issues of kinship, sovereignty, and traditional ideas of labor and land led to the creation of complex policies regarding freedpeople in the Choctaw Nation. Choctaw Confederates succeeds mostly because of the careful use of oral histories and “side-streaming” in order to flesh out a story many considered difficult to tell due to a dearth of sources (p. 9). Using oral histories from the Indian Pioneer History Collection and ex-slave narratives recorded by the Works Progress Administration in Oklahoma, Yarbrough is able to tell this story from multiple perspectives, including those of enslaved people in Indian Territory. She uses sources from other Indian nations to supplement sources from the Choctaw Nation itself, allowing her to build a more detailed and nuanced understanding of how slavery and sovereignty informed decision making among Native peoples in the Civil War era. Christine A. Rizzi Broward College Copyright © 2023 The Southern Historical Association

Abstract A101: Exploring facilitators and barriers to low-dose CT screening for lung cancer among Native American patients: The TEALS study

Abstract Purpose: Lung cancer screening (LCS) with low dose CT scanning reduces mortality but uptake of LCS is poor. Lung cancer mortality in Oklahoma’s Native American population is 45% higher than for the non-Hispanic White population. The Tribally Engaged Approaches to Lung Screening (TEALS) study is a collaboration between the University of Oklahoma Health Sciences Center and the Choctaw Nation of Oklahoma Health Services Authority (CNHSA). The goals of TEALS are to implement a systematic LCS program within Choctaw Nation and to understand LCS decision-making processes, barriers and facilitators. Procedures: Using purposive sampling from 2 of 8 CNHSA clinics in Oklahoma in 2021, we conducted a pilot study using phone interviews with patients who had completed LCS and those who had not. Using a semi-structured interview guide, we asked patients about their experience with the LCS program, factors that influenced their decision, and suggestions for improving the program. Conventional inductive content analysis was used to identify major themes. Multiple coders and peer debriefing enhanced scientific rigor. Results: Completers (4 men and 5 women) and non-completers (3 men and 3 women) were included. Major themes included: (1) Contextual factors influencing the decision-making process; (2) Individual characteristics influencing the decision-making process; and (3) Barriers to screening. Contextual factors included the provider raising the discussion of LCS, which was most frequently cited by completers but not the non-completers. Other contextual factors included the use of handouts and pamphlets during clinic visits. Patient suggestions included brochures/posters in waiting rooms and creating an information video to run on TVs in waiting areas. Individual characteristics included motivation to ‘be there’ for family/children, previous cancer in family/friends, and ease of arranging appointments. Non-completers preferred not to know or were scared to know the results of screening. Barriers included long distance travel to LCS sites, missing work, access to transportation or assistance, confusion about the appointment leading to missed appointments. Interviews highlighted the need to clarify eligibility criteria. Notably, some patients who were classified as ‘non-completers’ had already had a diagnostic CT for respiratory symptoms or as follow-up for prior cancer, indicating a gap in correctly identifying LCS eligibility. Conclusions: Findings from this pilot have guided implementation of the TEALS clinical trial. Large banners are now available in participating clinics. Academic detailing ensures the decision aid pamphlet is available and used in waiting rooms. Providers are reminded of the critical role they play in informing patients about LCS. Appointment reminders and assistance with transportation (e.g., tribal transportation) are in place. Eligibility criteria for the clinical trial have been clarified. Gathering this information from pilot study participants has enabled the team to refine the LCS intervention as it expands to other sites. Citation Format: Kathleen Dwyer, Dorothy A. Rhoades, Mark Doescher, Brook McCann, Michele Gibson, Zsolt Nagykaldi. Exploring facilitators and barriers to low-dose CT screening for lung cancer among Native American patients: The TEALS study [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A101.

Little Chahta News Bird: Indigenous Periodicals and the Performance of Nationhood

ABSTRACT: This article explores the Biskinik , a monthly newspaper produced by the Choctaw Nation of Oklahoma and in continuous circulation since 1978. It draws together methodological and theoretical investments from Native American and Indigenous Studies and Performance Studies in order to demonstrate how tribal newspapers such as the Biskinik are active sites of nations performing themselves. They curate actions and enact a story in which the nation is central. Explicating how performance and performativity reveal the ongoing process of Indigenous sovereignty within periodical publication, the article focuses on a 2022 issue of the Biskinik . It argues that the Biskinik should be read as a curation of Choctaw performance and a performance of Choctaw-ness, and as such the newspaper enacts nationhood in a complex and continuous movement of connection.

Ishki, Mother, upon Leaving the Choctaw Homelands, 1831

Ishki, Mother, upon Leaving the Choctaw Homelands, 1831 Leanne Howe (bio) Right here is where I once suckled babies into Red peopleRight here we grew three sisters into Corn, Beans, and SquashRight here we gave goods to all who hungeredRight here we nurtured abundance. Right here my body was a cycle of giving untilTorn from our homelands by the Naholla, andAndrew Jackson, the duteous seamsterIntent on opening all veins. Right here there's a hole of sorrow in the center of my chestA punctureA chasm of muscleSinewBones Right here I will stitch my wounds and live onAnd sing,And sing,I am singing, still. [End Page 7] Leanne Howe University of Georgia Leanne Howe leanne howe is a member of the Choctaw Nation of Oklahoma and is Eidson Distinguished Professor in the Department of English at the University of Georgia. She has received a United States Artists (USA) Ford Fellowship, a Lifetime Achievement Award from the Native Writers' Circle of the Americas, an American Book Award, and an Oklahoma Book Award, and she was a Fulbright Distinguished Scholar to Jordan. She is author or editor of several award-winning plays and books, from Shell Shaker (2001) to Savage Conversations (2019). Copyright © 2023 The University of North Carolina Press

Medication Adherence and Cardiometabolic Control Indicators Among American Indian Adults Receiving Tribal Health Services: Protocol for a Longitudinal Electronic Health Records Study.

American Indian adults have the highest prevalence of type 2 diabetes (T2D) in any racial or ethnic group and experience high rates of comorbidities. Uncontrolled cardiometabolic risk factors-insulin resistance, resulting in impaired glucose tolerance, dyslipidemia, and hypertension-increase the risk of mortality. Mortality is significantly reduced by glucose- and lipid-lowering and antihypertensive medication adherence. Medication adherence is low among American Indian adults living in non-Indian Health Service health care settings. Virtually nothing is known about the nature and extent of medication adherence among reservation-dwelling American Indian adults who primarily receive their medications without cost from Indian Health Service or tribal facilities. Electronic health records (EHRs) offer a rich but underused data source regarding medication adherence and its potential to predict cardiometabolic control indicators (C-MCIs). With the support of the Choctaw Nation of Oklahoma (CNO), we address this oversight by using EHR data generated by this large, state-of-the-art tribal health care system to investigate C-MCIs. Our specific aims are to determine, using 2018 EHR data, the bivariate relationships between medication adherence and C-MCIs, demographics, and comorbidities and each C-MCI and demographics and comorbidities; develop machine learning models for predicting future C-MCIs from the previous year's medication adherence, demographics, comorbidities, and common laboratory tests; and identify facilitators of and barriers to medication adherence within the context of social determinants of health (SDOH), EHR-derived medication adherence, and C-MCIs. Drawing on the tribe's EHR (2018-2021) data for CNO patients with T2D, we will characterize the relationships among medication adherence (to glucose- and lipid-lowering and antihypertensive drugs) and C-MCIs (hemoglobin A1c ≤7%, low-density lipoprotein cholesterol <100 mg/dL, and systolic blood pressure <130 mm Hg); patient demographics (eg, age, sex, SDOH, and residence location); and comorbidities (eg, BMI ≥30, cardiovascular disease, and chronic kidney disease). We will also characterize the association of each C-MCI with demographics and comorbidities. Prescription and pharmacy refill data will be used to calculate the proportion of days covered with medications, a typical measure of medication adherence. Using machine learning techniques, we will develop prediction models for future (2019-2021) C-MCIs based on medication adherence, patient demographics, comorbidities, and common laboratory tests (eg, lipid panel) from the previous year. Finally, key informant interviews (N=90) will explore facilitators of and barriers to medication adherence within the context of local SDOH. Funding was obtained in early 2022. The University of Florida and CNO approved the institutional review board protocols and executed the data use agreements. Data extraction is in process. We expect to obtain results from aims 1 and 2 in 2024. Our findings will yield insights into improving medication adherence and C-MCIs among American Indian adults, consistent with CNO's State of the Nation's Health Report 2017 goal of reducing T2D and its complications. PRR1-10.2196/39193.

Choctaw Confederates: The American Civil War in Indian Country by Faye A. Yarbrough

Reviewed by: Choctaw Confederates: The American Civil War in Indian Country by Faye A. Yarbrough Andrew K. Frank (bio) Choctaw Confederates: The American Civil War in Indian Country. Faye A. Yarbrough. Chapel Hill: University of North Carolina Press, 2021. ISBN 978-1-4696-6511-5, 280 pp., cloth, $32.95. In the early nineteenth century, the Choctaws faced unrelenting efforts by Southern states and politicians to dissolve their government, steal their land, and evict them from their homelands in Alabama and Mississippi. By early 1861, only decades after its forced removal west, the Choctaw Nation had allied itself with the Confederacy and those who had only recently declared that the South had no place for Native Americans. In Choctaw Confederates, historian Faye A. Yarbrough unravels this contradiction by exploring the importance of slavery and tribal sovereignty to nineteenth-century Choctaw society. Yarbrough primarily uses treaties, council meeting records, and laws to explain the development of nineteenth-century Choctaw society and ultimately [End Page 331] explain the decision of the nation to ally with the Confederacy. Yarbrough incorporates the voices of the enslaved and nonelite Choctaws and has mined military service records to discuss the enthusiasm and experiences of soldiers during the war. Most of the volume, however, focuses on those involved in making the political decisions and voicing official explanations. Yarbrough’s conclusions will often feel familiar to scholars of the Confederacy, but they consistently appear as peculiarly Choctaw variations. Yarbrough begins Choctaw Confederates with a sustained discussion of how slavery transformed and permeated Choctaw society prior to forced removal and in the following decades in Indian Territory. This discussion uses the Records of the Choctaw Council Meetings as well as interviews later recorded by the Works Progress Administration and in the Indian Pioneer History Collection to augment a rich secondary literature. As Choctaws increasingly became market-oriented enslavers, they wrote new laws that eroded traditional clan obligations and redefined property. Yarbrough argues that Choctaws pursued these changes to protect the interests of enslavers as well as to convince Southern and federal governments that the Choctaws were “independent and sovereign, with a distinct culture and identity” (13). Like white enslavers to the east, the council restricted literacy for enslaved people and enacted other legal restrictions on Blacks in the nation. Simultaneously, it defended the Choctaws’ sovereign boundaries and the property of Choctaw wives by regulating marriages with white outsiders. Yarbrough’s examination of the Choctaws’ decision to form an alliance with the Confederacy emphasizes their fear over the future of both slavery and tribal sovereignty. Council members, for example, worried that federal policies toward Kansas and Nebraska left Choctaw land claims in a precarious situation. They also concluded that the creation of the Confederacy dissolved the US government and thereby rendered all past treaties meaningless. These fears, Yarbrough explains, shaped the Choctaw Nation’s negotiations with the Confederacy. It unsuccessfully sought political representation and statehood in the Confederacy, but it won many concessions from the Confederacy that acknowledged their sovereignty. In addition, Choctaws “hoped that a strong commitment to states’ rights would translate into respecting Native sovereignty rights as well” (2). Yarbrough’s discussion of Choctaw soldiers and their motivations offers the book’s most novel contribution. These discussions, as well as her vivid reconstruction of the experiences and observations of the enslaved, push Yarbrough away from the volume’s focus on elite leaders and political discourse. Her analysis of the service records of the First Choctaw and Chickasaw Mounted Rifles [End Page 332] reveals a nation whose men appear more eager to enlist than white Southerners and whose zeal for fighting waned as the conflict continued. This argument rests, in part, on the number and percentage of Choctaw enlistees. Without a draft to coerce service, the Choctaws mustered 3,100 soldiers (20 percent) of its non-enslaved population, according to Yarbrough’s calculation. This number is significantly higher than the modern Choctaw Nation’s estimate of 1,200 and slightly higher than estimates for the United States and the Confederacy. Yarbrough’s total, though, is certainly inflated as it includes some Chickasaws, “likely some duplication” of records and “soldiers . . . [who] were also white” (118, 119). Her discussion of Choctaw...

Evaluating the Impact of a Tribal Naloxone Program Through Pre and Post Surveys from First Responders.

The Choctaw Nation Health Care Center established a first responder naloxone program in 2015. Limited data is available on community naloxone programs specific to tribal communities and the opinions of first responders who may utilize naloxone in the field. The purpose of this article is to highlight the model of a tribal first responder naloxone program in Talihina, Oklahoma and present analysis of the impact of program trainings on first responders' understanding and willingness to administer intranasal naloxone through pre- and post-surveys (n = 758) collected from May 2018 to November 2019. Descriptive analyses were conducted to compare first responders' rating of their support, willingness, and confidence in using naloxone. Overall, 95.1% of first responders reported learning something new from the training. However, the most significant changes in pre- to post-test results were among first responders that had never been at the scene of an overdose. Almost 77% of trainees who reported they never were at a scene of an overdose and responded "not very willing" in administering naloxone at pre-test, responded that they were "very willing" to administer naloxone at post-test.

Choctaw Confederates: The American Civil War in Indian Country by Fay A. Yarbrough

Reviewed by: Choctaw Confederates: The American Civil War in Indian Country by Fay A. Yarbrough Clarissa W. Confer Choctaw Confederates: The American Civil War in Indian Country. By Fay A. Yarbrough. (Chapel Hill: University of North Carolina Press, 2021. Pp. 280. Illustrations, notes, bibliography, index.) This slim volume traces the Choctaws’ wartime experience in a few chapters, which are book-ended by other chapters covering traditional Choctaw culture and the Reconstruction period, including an unpersuasive foray into the imagined effect of war on masculinity. The author’s research entails a fairly standard use of available sources—tribal nation papers, the Indian-Pioneer Papers collection at the University of Oklahoma, W.P.A. narratives, and government records—that I, Mary Jane Warde, and others have also used in analyzing the nations of Indian Territory in the mid-nineteenth century. In this case, Fay Yarbrough looks at the material through the lens of slavery and race relations. Her expressed intent to connect this past to issues of the present sets the tone for her work. The book begins with a standard history of the Choctaw people, explaining traditional aspects of social structure, such as matrilineal descent and the role of clans. Like so many Native groups, the Choctaws experienced extensive change in the nineteenth century, brought on primarily by White expansion westward. One example is gender roles. As the century progressed, Native women lost their status as agricultural producers. Although the author attributes this entirely to the development of slavery, this change actually stems from a wide range of factors, most notably White male expectations. In that and many other ways, Choctaw society began to look more like White southern culture. The Choctaw were one of the five Native nations removed to Indian Territory from the southeastern United States who practice slavery; however, because enslaved people made up only 14 percent of the Choctaw population by 1860, a much smaller percentage than in any of its neighboring states, there are marked differences between Choctaw culture and the Deep South. Unlike in slave states, the Choctaw nation had a path for citizenship for slaves through blood ties to a Choctaw. Deep South plantations would have looked very different had White masters offered citizenship to blood relations among their slaves. Like their slaveholding neighbors, however, the Choctaw also tightened the legal structure governing bondage in the post-Nat Turner period of the 1830s. Although Choctaw citizens’ engagement in this slave economy influenced their decision to participate in the Civil War, this was only one of several such influences. The question of how and why Indian nations chose sides in the national conflict has been examined and debated in many books, and Yarbrough revisits that question. The core principle for all the nations was tribal sovereignty, and the attractive alliance package offered by Confederate leaders seemed the best way to preserve it. The Choctaw followed a path [End Page 124] similar to the Cherokees, seeking neutrality first, eventually allying with the Confederacy, and then forming armed mounted units for the Confederate army. The author leans heavily on Cherokee history to flesh out the story of the Choctaw, but the problem with this strategy is that the Cherokee were uniquely divided by the removal experience, and those fissures shaped their responses. In contrast to the Cherokee, the Choctaw remained loyal to the Confederacy throughout the war, despite breeches of treaty promises. The Confederacy, for that matter, did not adequately support any of its Native allies, resulting in poor wartime conditions, desertions, and leadership lapses among them. The Civil War in Indian Territory, as scholars have been arguing for decades, devolved into an internal civil war. No Native nation gained from the experience. The Choctaw location on the southern edge of Indian Territory made that area a popular destination for a flow of refugees from the war, which put corresponding pressures on the nation, although that is not discussed here. Even so, the Choctaw maintained their unity throughout the war. Unfortunately, the chapter about Reconstruction focuses only on the Choctaw freedpeople and does not examine the intriguing situation in which Choctaws negotiated a more favorable peace treaty than the other nations who fought the United States. The...

1228-P: Medication Adherence and Cardiometabolic Control in American Indians with Type 2 Diabetes: Pilot Study

Introduction: American Indians (AIs) have high rates of type 2 diabetes (T2D) and comorbidities. Mortality risk is increased by uncontrolled cardio-metabolic factors and significantly reduced by antihypertensive, glucose- and lipid-lowering medication adherence. Medication adherence is low among AIs living in non-Indian Health Services (IHS) healthcare settings, but little is known about medication adherence among AIs who primarily receive their medications from IHS/tribal facilities. The study aim was to identify cardio-metabolic control factors (hemoglobin A1c [HbA1c], low density lipoprotein [LDL-C], and systolic blood pressure [SBP]) and antihypertensive, glucose- and lipid-lowering medication adherence in adults with T2D who use Choctaw Nation of Oklahoma (CNO) Health Services. Methods: Enrolled CNO tribal members with T2D over 18 years of age with at least one pharmacy visit and at least one HbA1c measure in 2017 (N=5,970, mean age 58.0±13.4, 52% female) were included in this descriptive pilot study. We used the earliest values of HbA1c, LDL-C and SBP in the measurement period. Medication adherence (proportion of days covered [PDC]) was calculated using 2017 CNO electronic health record (EHR) data. Medication classes included biguanides, statins, and ACE/ARBs. Results: Fifty-six percent had HbA1c measurements above the target of 7%, 42% had LDL-C greater than 100mg/dL, and 63% had SBP above target of 130 mmHg. Thirty-six percent had both HbA1c and SBP levels above target. The percentage of patients with PDC ≥.80 was 63% for biguanides, 66% for statins, and 70% for ACE/ARBs. Discussion/Conclusions: Previous studies have reported similar findings for cardio-metabolic control factors as well as higher medication adherence rates. Future studies should focus on examining prescription and pharmacy refill data longitudinally and should include a subgroup of patients to understand facilitators of and barriers to medication adherence not available within EHR data. Disclosure T.N. Nelson: None. Y. Yao: None. A. DeVaughan-Circles: None. D.J. Wilkie: Other Relationship; eNursing llc. L. Scarton: None.

Museums and Renewed Relations: Choctaw-French Nations of the Eighteenth Century and Present

In a recent exhibit, the Choctaw Nation of Oklahoma, Musée du quai Branly-Jacques Chirac, and Bibliothèque Municipale de Versailles worked together to learn more about the museum’s royal Americas collection which features items from numerous Indigenous communities. Collected by French explorers during the eighteenth century and later displayed in royal curiosity cabinets, these items have not been seen by Choctaw communities since they left the continent. This collaboration has culminated in the “La Curiosité d’un Prince” exhibit, which features a room curated by Choctaw Nation. This article shows how a joint initiative to study the collection gave voice to the relationships and material histories inherent in the items. Reflecting on this less-known historical period, this collaboration has reinvigorated Choctaw-French relations and allowed Choctaw Nation to showcase the richness and complexity of its sovereignty—which is often narrowly understood through its relationship with the United States. By providing an example of true collaboration that has spurred new research and writing on both the cultural and political knowledge contained in the objects held in France, we demonstrate the potential for relationships and knowledge inherent in museum collections to act as a platform for new expressions of Indigenous sovereignty.