Indian Health Clinic Research Articles

Implementation of medication for opioid use disorder treatment in Indian health clinics in California: A qualitative evaluation

IntroductionAmerican Indians and Alaska Native (AIAN) populations are disproportionately affected by opioid misuse. Medication for opioid use disorder (MOUD) is essential to decrease overdose events and overdose deaths. AIAN communities can benefit from MOUD programs that are housed within primary care clinics to improve treatment accessibility. This study aimed to gather information on the needs, barriers, and successes related to implementing MOUD programs in Indian health clinics (IHCs) offering primary care. MethodsThe study used the Reach, Effectiveness, Adoption, Implementation, and Maintenance Qualitative Evaluation for Systematic Translation (RE-AIM QuEST) evaluation framework to structure key informant interviews with clinic staff who received technical assistance for MOUD program implementation. The study incorporated RE-AIM dimensions into a semi-structured interview guide. We developed the coding approach for analyzing interview data using Braun and Clarke's (2006) reflexive thematic analysis in qualitative research. ResultsEleven clinics participated in the study. The research team conducted twenty-nine interviews with clinic staff. We found that inadequate education about MOUD, scant resources, and limited availability of AIAN providers adversely impacted reach. Challenges with integrating medical and behavioral care, patient-level barriers (e.g., rural conditions, geographical dispersion), and limited workforce capacity impacted MOUD effectiveness. Stigma at the clinic level was detrimental to MOUD adoption. Implementation was challenging due to a limited number of waivered providers, and the need for technical assistance and MOUD policies and procedures. Staff turnover and restricted physical infrastructure negatively influenced MOUD maintenance. ConclusionsClinical infrastructure should be strengthened. The integration of culture into clinic services must be embraced by staff to support MOUD adoption. Increased representation from AIAN clinical staff is needed to appropriately represent the population being served. Stigma at various levels must be addressed, and the multiple barriers that AIAN communities face must be considered in understanding MOUD program implementation and outcomes.

Conceptualizing culture in (global) mental health: Lessons from an urban American Indian behavioral health clinic

The movement for global mental health (GMH) has brought perennial questions about human diversity in mental health to the fore through heightened debates over if and how established knowledge, institutions, and practices should be altered for ethical and effective interventions with diverse peoples around the world. Kirmayer and Pedersen (2014) encouraged dialogue between GMH scholars and communities considered for intervention to address differences and concerns about colonialism. American Indian mental health offers an instructive site for global mental health inquiry to understand frameworks that might facilitate this desired dialogue. Here, we draw from a clinical ethnography in urban American Indian behavioral health conducted between September 2014 and February 2015 to glean insights into a popular response to these differences: Incorporating Indigenous cultural forms into clinical practice. Our findings highlight a predicament this response presents to mental health professionals. They can either eschew their clinical training and its cultural assumptions to take up new lives enabling their representation of Indigenous cultural forms, or they can hold onto their professional training and modify what is clinically familiar to appear culturally different. Rather than a purposeful decision, in the clinic contextual factors—tacit assumptions, clinic structures, and popular culture concepts—powerfully shaped clinical practice and reconfigured Indigenous cultural forms to support familiar clinical processes (e.g., treatment-planning). Although potentially therapeutic, culturally repackaged mental health practices are not the therapeutic alternatives called for by many Indigenous communities, and when advertised as such, risk harmful appropriations and misleading reticent people into participating in culturally prescriptive interventions. Lessons for global mental health point away from incorporating Indigenous cultural forms into clinical practice, which is likely to result in cultural repackaging, toward ethnographically-informed dialogue of differences to inform models for medical and epistemic pluralism providing interested communities more culturally commensurate mental health services alongside well-supported Indigenous therapeutic alternatives.

An interview-based evaluation of an Indigenous traditional spirituality program at an urban American Indian health clinic.

American Indians suffer from disproportionately high rates of mental health problems. Professional therapies may not meet the specific mental health needs of American Indians, owing to cultural mismatch and long histories of political disempowerment. Instead, Indigenous traditional spiritual practices are often promoted as alternative sources of health and help in these communities. In response to a community needs assessment, we developed a 12-week traditional spirituality curriculum in partnership with the urban American Indian health clinic in Detroit. Centered on the sweat lodge ceremony, the program was pilot tested with 10 community members. Semi-structured interviews were conducted with nine participants following the program. Based on our analyses, all participants endorsed responses within two overarching themes: impact on personal well-being, and suggestions for improvement reflecting their desire for an ongoing program. Participant responses about the program's impact comprised four themes: (1) improved psychological and spiritual well-being, (2) community benefit, (3) increase in cultural knowledge, and (4) a desire for further learning and sharing. Participant responses about their desire for an ongoing program also comprised four themes: (1) drop-in classes may be more practical as regular attendance was difficult for some, (2) future classes should include more areas of knowledge, (3) the program could be expanded to include more knowledge-holders and perspectives, and (4) the program should include a progression of classes to accommodate more diversity. Overall, participants reported benefit from participation in Indigenous spiritual practices; however, the program can be improved by further adapting the curriculum to the sometimes-challenging lives of its participants.

Improving Organizational Sustainability of an Urban Indian Health Clinic With an Innovative Pharmacy Model.

Introduction:To increase access to care for the urban American Indian population, a collaboration was developed between an Urban Indian Health Clinic (UIHC) and Federally Qualified Healthcare Center (FQHC) to reduce financial barriers, increase patient access to affordable medications, and augment the integrated model of care.Objective:To describe the design and implementation of an innovative pharmacy model through a partnership between an UIHC and a FQHC.Methods:A collaborative partnership between an UIHC and a FQHC was developed to spread scarce 340B federal resources as a method to enhance patient care. The innovative practice model included the development of processes to (1) increase medication access to all patients by providing access to affordable medications at clinic and the provision of mail order services, (2) minimize program expenses through cost-sharing of a pharmacist salary, (3) expand clinical pharmacy programs (collaborative drug therapy management) to augment integrated patient care, and (4) optimize 340B cost savings for the clinic by establishing contracts and implementing adjudication software to obtain medication reimbursement from Medicaid and other third party insurances.Results:Through the cost-sharing of a pharmacist salary and use of remote verification, the majority of prescription medications were available to patients at the UIHC through implementation and expansion of an other outlet. Collaborative drug therapy management (CDTM) protocols were successfully implemented which allowed clinical pharmacy services to collaboratively manage chronic conditions. All adult primary care providers adopted the integrated patient care model. Third-party pharmacy insurance contracts were obtained and computer software was installed to allow for the adjudication of pharmacy claims, resulting in cost savings from medication reimbursement.Conclusion:The innovative collaborative partnership between an UIHC and an FQHC demonstrated how scarce federal resources can be leveraged using the 340B program to increase patient access to affordable medications. This innovative model reduced financial barriers to the clinic, and allowed for expansion of pharmacist led CDTM programs and augmentation of integrated clinical services. The cost savings observed from this novel program additionally fueled programmatic sustainability through reinvestment into the pharmacy program and is expected to continue to fund the program in the future.

Assessing the Interest and Cultural Congruence of Contingency Management as an Intervention for Alcohol Misuse Among Younger American Indian Adults.

A qualitative study was conducted to assess interest in contingency management (CM) for younger American Indian (AI) adults (18-29 years old), how to culturally and developmentally adapt CM for younger AI adults, and interest in CM relative to culturally grounded treatment approaches. We conducted a total of four focus groups with younger adults and families in two AI communities: a rural reservation and an urban Indian health clinic (n = 32). Four overarching themes emerged suggesting that offering prizes, cultural activities, and activities that capture the attention of younger adults integrated into the CM intervention is ideal for enhancing engagement.

Feasibility of a Systems Approach to Treat Commercial Tobacco Dependence within American Indian Health Clinics.

American Indians and Alaska Natives (AI/ANs) have the highest smoking prevalence, smoking-related disease, and mortality rates of any racial or ethnic group. Three AI health clinics in Minnesota implemented an evidence-based tobacco dependence treatment intervention that included provider education and customized clinical system tools. A baseline assessment of each clinic facility guided the focus of the intervention and tailored the clinical system tools. Clinic staff were assessed with pre/post-training evaluations and annual assessments. Results indicated self-reported improvements in the rate of identifying smoking status (57% to 89%), documenting smoking status (from 60% to 80%), and providing evidence-based treatments such as pharmacotherapy (from 36% to 78%).

An urban American Indian health clinic's response to a community needs assessment.

Utilizing community-based methods, we assessed the behavioral and physical health needs of a Detroit metropolitan Indian health clinic. The project goal was to identify health service needs for urban American Indians/Alaska Natives and develop the infrastructure for culturally competent and integrative behavioral and physical health care. We conducted 38 semi-structured interviews and 12 focus groups with service providers and community members. Interview and focus group data indicated a need for 1) more culturally competent services and providers, 2) more specialized health services, and 3) more transportation options. We then report on the Indian health clinic's and community's accomplishments in response to the needs assessment.

Satisfaction with cancer care among American Indian and Alaska Natives in Oregon and Washington State: a qualitative study of survivor and caregiver perspectives.

To better understand satisfaction with care among American Indian and Alaska Native (AI/AN) persons with cancer, we explored dimensions of the provider relationship that contributed to satisfaction among caregivers and survivors who received cancer treatment in Oregon and Washington State. Between November 2011 and April 2013, the project team interviewed 11 caregivers and 71 AI/AN cancer survivors residing in Oregon and Washington State. Interview questions aimed to elicit participant experiences with care providers and factors associated with cancer care satisfaction. Interviews were analyzed using an inductive content analysis approach in which concepts were identified and themes derived from interview data. Three overarching themes, each with two sub-themes, emerged from the data: (1) universal factors: bolstering understanding, involvement, and empathy in care; (2) minority-specific factors: incorporating culture and community into care; and (3) AI/AN-unique factors: interacting with Indian health clinics and Indian Health Service (IHS). The results of our study suggest that satisfaction with care among survivors and their caregivers must be examined within the context of culture and community, particularly among minority patients. Our study demonstrates providers' critical role in ensuring AI/AN patients emerge satisfied with cancer treatment by honoring their AI/AN-specific needs, such as respect for integration of traditional healing modalities and navigation of specialty care coordination.

Look Local: The Value of Cancer Surveillance and Reporting by American Indian Clinics

IntroductionCancer incidence and mortality rates for American Indians in the Northern Plains region of the United States are among the highest in the nation. Reliable cancer surveillance data are essential to help reduce this burden; however, racial data in state cancer registries are often misclassified, and cases are often underreported.MethodsWe used a community-based participatory research approach to conduct a retrospective ascertainment of cancer cases in clinic medical records over a 9-year period (1995–2003) and compared the results with the state cancer registry to evaluate missing or racially misclassified cases. Six tribal and/or urban Indian clinics participated in the study. The project team consisted of participating clinics, a state cancer registry, a comprehensive cancer center, an American Indian/Alaska Native Leadership Initiative on Cancer, and a set of diverse organizational partners. Clinic personnel were trained by project staff to accurately identify cancer cases in clinic records. These records were then matched with the state cancer registry to assess misclassification and underreporting.ResultsForty American Indian cases were identified that were either missing or misclassified in the state registry. Adding these cases to the registry increased the number of American Indian cases by 21.3% during the study period (P = .05).ConclusionsOur results indicate that direct reporting of cancer cases by tribal and urban Indian health clinics to a state cancer registry improved the quality of the data available for cancer surveillance. Higher-quality data can advance the efforts of cancer prevention and control stakeholders to address disparities in Native communities.

Development and Validation of prediction for estimating resting energy expenditure in Indian subjects.

Assessment of energy intake and expenditure is an important criteria for nutrition care plan. Equation for predicting Resting Energy Expenditure (REE) or Resting Metabolic Rate (RMR) is based on body weight, height, sex and FFM. Resting Energy Expenditure (REE) is an important parameter, which estimate metabolic rate in obese and underweight individuals. Different formulas are used to estimate energy requirements in Indian health clinics. But to our no precise study has has been done in this area, so far. The aim of the present paper was to develop and predict Resting Energy Expenditure, for Indian subjects. For this 100 Indian subjects, participated in the study whose Human Body composition parameters, like sex, Impedance, RMR, BMI (Basal Metabolic Index), were measured experimently by Maltron-II Body composition Analyser. Two different sets of Resting Energy Equations were developed. First with sex, age, weight and Impedance Index at different frequencies of 5 KHz, 50KHz, 100KHz and 200 KHz. Second with independent variables as FM, FFM and age and sex.The results obtained were then validated with the Maltron-II Body composition analyser and it was found that the results were in close proximity with the results obtained from instrument. In addition to this statistical Analysis of the data is carried out with the help of statistical software R version (2.9.2) which is useful to study the correlation obtained from the the Instrument, and that obtained by scientists. Further different other parameters of statistics is formulated in tabular form.

Usefulness of a Survey on Underage Drinking in a Rural American Indian Community Health Clinic

This study examined the usefulness of a survey on underage drinking in a rural American Indian community health clinic. One hundred ninety-seven youth (90 male, 107 female; age range 8-20 years) were recruited from clinic waiting rooms and through community outreach. The study revealed that the usefulness of the survey was twofold: Survey results could be used by clinic staff to screen for underage drinking and associated problems in youth served by the clinic, and the process of organizing, evaluating, and implementing the survey results accomplished several important goals of community-based participatory research.

Factors Associated with American Indian Cigarette Smoking in Rural Settings

Introduction:This paper reports on the prevalence, factors and patterns of cigarette smoking among rural California American Indian (AI) adults.Methods:Thirteen Indian health clinic registries formed the random household survey sampling frame (N = 457). Measures included socio-demographics, age at smoking initiation, intention to quit, smoking usage, smoking during pregnancy, health effects of smoking, suicide attempts or ideation, history of physical abuse, neglect and the role of the environment (smoking at home and at work). Statistical tests included Chi Square and Fisher’s Exact test, as well as multiple logistic regression analysis among never, former, and current smokers.Results:Findings confirm high smoking prevalence among male and female participants (44% and 37% respectively). American Indians begin smoking in early adolescence (age 14.7). Also, 65% of current smokers are less than 50% Indian blood and 76% of current smokers have no intention to quit smoking. Current and former smokers are statistically more likely to report having suicidal ideation than those who never smoked. Current smokers also report being neglected and physically abused in childhood and adolescence, are statistically more likely to smoke ½ pack or less (39% vs. 10% who smoke 1+ pack), smoke during pregnancy, and have others who smoke in the house compared with former and never smokers.Conclusion:Understanding the factors associated with smoking will help to bring about policy changes and more effective programs to address the problem of high smoking rates among American Indians.

Safer Sexual Practices and HIV Screening Behavior among Rural California American Indians

This paper reports on safer sexual practices and HIV screening behavior among rural California American Indians. Thirteen Indian health clinic registries formed the random household survey sampling frame (N=457). Measures included socio-demographics, safer sexual practices, HIV testing, high-risk behaviors, perception of wellness, general health status, neglect, physical and sexual abuse history. Statistical tests included chi-square and Fisher's exact tests, as well as multiple logistic regression analysis. Respondents who practiced safer sex were younger, not married, reported lower annual income, changed sexual behavior in the last 12 months, were not in a monogamous relationship, and had a higher perception of wellness. Those who were tested for HIV were younger, had at least a high school education, consumed alcohol, had significantly higher suicide ideation and attempts, changed their sexual behavior in the last 12 months, and reported a history of sexual abuse as a child and adult. Very little is known about HIV prevention and screening behaviors in rural American Indian populations. Identifying predictors of unsafe sexual practices and non-HIV testing tendencies help to plan for measures to protect the population from this devastating disease. We make recommendations for implementing HIV prevention education and screenings at American Indian clinics.

ORIGINAL RESEARCH: Characteristics of risk in patients of nurse practitioner safety net practices

Abstract Purpose: The purpose of this article is to describe the characteristics of vulnerability in patients at safety net practices where nurse practitioners (NPs) provide the majority of the health care and to discuss the implications regarding patient data collection for all NPs who provide safety net care. Data Sources: Data were collected from patients at four safety net practices: a rural health clinic, a rural nurse‐managed health clinic, an urban nurse‐managed health clinic, and an urban Indian health clinic. Conclusions: The users of these practices reflected a significant degree of risk for poor health outcomes based on characteristics of risk identified in the literature. Patients seen in nurse‐managed health clinics without federal subsidies had more risk that those in federally supported clinics. Implications for Practice: Given the increasing evidence of the impact of social and environment factors on poor health outcomes, the importance of assessing and describing the characteristics of risk is discussed. These data are essential for supporting the value of these NP‐provided safety net services to healthcare insurers and federal health policy makers.

A Community-Specific Approach to Cancer Research in Indian Country

Health care leaders in a small, rural, American Indian community and university partners used the community-based participatory research (CBPR) method to survey cancer survivors. We sought to provide support for the use of CBPR to generate ideas for how to improve the detection and treatment of cancer in American Indian communities. Partners worked together to develop a mail-out survey and send it to the Indian health clinic's patients who had cancer in the past 5 years. The survey sought information on their experiences with cancer screenings, cancer diagnoses, and accessing and receiving cancer treatment. Community leaders identified three priority areas for intervention: (1) high incidence of breast cancer; (2) lack of culturally appropriate cancer education; and (3) need for a more in-depth assessment. CBPR's partnership principle allowed for results to be viewed within the community's context, availability of community resources, and relevant cultural beliefs and traditions.

Patients Benefit From Merged Traditions

Patients Benefit From Merged Traditions

Access to Specialty Health Care for Rural American Indians in Two States

The Indian Health Service (IHS), whose per capita expenditure for American Indian and Alaska Native (AI/AN) health services is about half that of the US civilian population, is the only source of health care funding for many rural AI/ANs. Specialty services, largely funded through contracts with outside practitioners, may be limited by low IHS funding levels. To examine specialty service access among rural Indian populations in two states. A 31-item mail survey addressing perceived access to specialty physicians, barriers to access, and access to non-physician clinical services was sent to 106 primary care providers in rural Indian health clinics in Montana and New Mexico (overall response rate 60.4%) and 95 primary care providers in rural non-Indian clinics within 25 miles of the Indian clinics (overall response rate 57.9%). Substantial proportions of rural Indian clinic providers in both states reported fair or poor non-emergent specialty service access for their patients. Montana's rural Indian clinic providers reported poorer patient access to specialty care than rural non-Indian clinic providers, while New Mexico's rural Indian and non-Indian providers reported comparable access. Indian clinic providers in both states most frequently cited financial barriers to specialty care. Indian clinic providers reported better access to most non-physician services than non-Indian clinic providers. Reported limitations in specialty care access for rural Indian clinic patients appear to be influenced by financial constraints. Health care systems factors may play a role in perceived differences in specialty access between rural Indian and non-Indian clinic patients.

Measuring the quality of diabetes care in urban and rural Indian health programs.

The purpose of this study was to compare the quality of diabetes care provided to American Indians/Alaska Natives (AI/AN) by urban and rural Indian health programs. Medical record review data collected by the Indian Health Service as part of the Diabetes Care and Outcomes Audit in 2002. Seventeen urban Indian health clinics and 225 rural Indian health programs. All urban AI/AN patients (n = 710) and random sample records of rural AI/AN patients (n=1420). Adherence to guidelines for process measures and intermediate outcomes of diabetes care. Compared to the rural sample, urban patients were more likely to have received diabetes education during the prior year (P < or = .05). Annual dental examinations were less common among urban patients than rural patients (19% vs 41%, P < or = .001). Completion of laboratory testing and immunizations were similar in both groups. Adjusted mean levels for intermediate outcomes of diabetes care and the percentage achieving recommended levels varied slightly but were not statistically or clinically significant. Few differences in the quality of diabetes care were found between urban and rural Indian health sites. Differences in the receipt of dental examinations may reflect differences in resources and staffing between urban and rural settings. This study serves as a baseline for the assessment of ongoing interventions aimed at improving the quality of care.

Characteristics of American Indian Women Cigarette Smokers: Prevalence and Cessation Status

A high rate of cigarette smoking is documented among the American Indian population in California, but data on Indian women smokers have not been widely studied. This paper reports on a survey conducted in a smoking cessation project implemented and evaluated as part of a National Cancer Institute (NCI) cooperative agreement. Characteristics of Indian women smokers are presented and cessation status is examined. The overall goal of the project was to increase long-term smoking cessation among American Indian populations through a reproducible clinic-based smoking cessation program. To ascertain smoking prevalence and tobacco use patterns, a self-administered survey was completed by 1,369 adult male and female American Indian health clinic users in Northern California. Study results reported several important characteristics of Indian women smokers. Single and divorced participants had a higher smoking rate (40.4% and 42%) than married participants (34.4%); 54.5% of unemployed women smoked; and level of education was strongly associated with smoking status (p=.011). Almost 80% (79.9%) of women former smokers quit using the ''cold turkey'' method. Fewer than 50% of Indian women smokers reported willingness to quit at the following smoking cessation stages: ''immediately'' or ''ready'' (12.4%), ''in one month'' (10.5%), and ''in six months'' (25.2%). This points to a need for effective tobacco cessation interventions for American Indians, which will take into consideration Indian women smokers' demographic characteristics, lenient attitudes toward smoking, and smoking behaviors.

The GAINS project: Outcome of smoking cessation strategies in four urban native american clinics

This study was designed to assess the capability of the Doctors Helping Smokers (DHS) model to produce an increase in smoking cessation over controls within four urban Indian Health clinics. A total of 601 Native American smokers were enrolled, surveyed, and measured for cardiovascular risk factors. Of those present in treatment clinics at 1-year follow-up, 7.1% reported being abstinent vs. 4.9% in the control group. Of those who made at least one visit to the clinic during the treatment year, 9.4% self-reported being abstinent in the treatment sites vs. 3.9% in the control group ( p = .04). Cotinine validated quits for all enrollees, regardless of whether they attended the clinic during the intervention, are 6.7% (intervention) and 6.8% (control). Number of quit attempts and future quit intentions were greater in the intervention group. Recommendations for future intervention efforts include earlier contact with clinicians, clinic involvement in preplanning, developing the program around the principles and realities of each site, building in more extensive components, and utilizing additional community resources.