Native American Veterans Research Articles

Associations Among Environmental Exposures and Physical and Psychiatric Symptoms in a Care-Seeking Sample of U.S. Military Veterans.

Recent research and policy (e.g., the Sergeant First Class (SFC) Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act) have highlighted the potential health consequences of toxic environmental exposures. The purpose of the current study was to assess the self-reported prevalence of such exposures among a sample of U.S. military veterans seeking care at a Veterans Affairs facility and to examine associations between exposures and physical and psychiatric symptoms. Participants were 4,647 newly enrolling post-9/11 veterans at the VA San Diego Healthcare System who completed standard clinical screening processes between January 2015 and April 2019. Electronic health screening data, including demographic information, military history, environmental exposures, and physical and psychiatric symptoms, were assessed. t-Tests for continuous variables and chi-square tests for categorical variables were used to compare exposed to unexposed veterans on demographic and military characteristics as well as physical and psychiatric symptoms. A total of 2,028 veterans (43.6%) reported exposure to environmental toxins during their military service. Analyses revealed a disproportionate burden of exposure on older, male, educated, combat veterans as well as Asian and Native American veterans. Exposure to any type of environmental toxin was associated with more physical symptoms, particularly pain, fatigue, and insomnia, as well as psychiatric symptoms, including moderate depressive symptomology, mild to moderate anxiety, and scores approaching the threshold for likely post-traumatic stress disorder and alcohol misuse. The high prevalence and detrimental health correlates of environmental exposures underscore the importance of implementing screening for exposures and providing healthcare services that address the multisystemic nature of exposure-related illness.

War and Veterans in Louise Erdrich's Novels

From the beginning of the Native American Renaissance, the subject matter of war tends to be significant to portray sufferings of emotional maladjustment among the Native American veterans who encountered the outside world through the war. Louise Erdrich is not an exception in dealing with the topics of war and veterans in her novels. Unlike some other writers, however, Erdrich does not give a hopeful ending to those veterans. The veterans are portrayed as victims and they cannot escape from the painful memories of war. The Native American veterans in particular, such as Cyprian, Billy Peace, Russell, and Henry Lamartine Jr., all have conspicuously fatal consequences arising from their participation in war, in one way or another, physically or emotionally. Each veteran has the fate of becoming an outcast or suffering a tragic death. Especially, the muted Henry Jr.’s drowning by committing suicide after his return from the Vietnam War manifests Erdrich’s powerful message about the brutal nature of war which also reminds the reader of the tragic history of Native Americans on the North American continent.

Culturally Centered Implementation of Video Telehealth for Rural Native Veterans.

Introduction: Native American Veterans are the most rural and experience heightened risk for mental health (MH) challenges while facing significant health care inequities and access barriers. Rural Native Veterans (RNVs) have experienced historical loss and racial discrimination, contributing to mistrust of Veterans Health Administration (VHA) and other Federal systems. Telemedicine, including video telehealth (VTH), can improve access to MH care for RNVs by addressing barriers. Understanding the cultural context and existing community resources can improve engagement and implementation efforts with RNVs. Objective: This article describes a model of culturally centered MH care and a flexible implementation approach, Personalized Implementation of Virtual Treatments for Rural Native Veterans (PIVOT-RNV), used to disseminate the model. Methods: Participants included four VHA sites serving large RNV populations where PIVOT-RNV was applied to expand the availability of virtual solutions, including VTH, for RNVs. A mixed methods formative evaluation tracked VTH utilization and used provider and RNV feedback to inform iterative process improvements. Results: Where PIVOT-RNV was used, number of providers using VTH with RNVs, number of unique RNVs receiving MH care through VTH, and number of VTH encounters with RNVs grew annually. Provider and RNV feedback highlighted the importance of addressing the unique barriers and cultural context of RNVs. Conclusions: PIVOT-RNV demonstrates promise for improving implementation of virtual treatments and access to MH care for RNVs. The integration of implementation science within a cultural safety framework helps address specific barriers to adoption of virtual treatments for RNVs. Next steps include expanding PIVOT-RNV efforts at additional sites.

Racial and ethnic disparities in excess mortality among U.S. veterans during the COVID-19 pandemic.

The COVID-19 pandemic disproportionately affected racial and ethnic minorities among the general population in the United States; however, little is known regarding its impact on U.S. military Veterans. In this study, our objectives were to identify the extent to which Veterans experienced increased all-cause mortality during the COVID-19 pandemic, stratified by race and ethnicity. Administrative data from the Veterans Health Administration's Corporate Data Warehouse. We use pre-pandemic data to estimate mortality risk models using five-fold cross-validation and quasi-Poisson regression. Models were stratified by a combined race-ethnicity variable and included controls for major comorbidities, demographic characteristics, and county fixed effects. We queried data for all Veterans residing in the 50 states plus Washington D.C. during 2016-2020. Veterans were excluded from analyses if they were missing county of residence or race-ethnicity data. Data were then aggregated to the county-year level and stratified by race-ethnicity. Overall, Veterans' mortality rates were 16% above normal during March-December 2020 which equates to 42,348 excess deaths. However, there was substantial variation by racial and ethnic group. Non-Hispanic White Veterans experienced the smallest relative increase in mortality (17%, 95% CI 11%-24%), while Native American Veterans had the highest increase (40%, 95% CI 17%-73%). Black Veterans (32%, 95% CI 27%-39%) and Hispanic Veterans (26%, 95% CI 17%-36%) had somewhat lower excess mortality, although these changeswere significantly higher compared to White Veterans. Disparities were smaller than in the general population. Minoritized Veterans experienced higher rates excess of mortality during the COVID-19 pandemic compared to White Veterans, though with smaller differences than the general population. This is likely due in part to the long-standing history of structural racism in the United States that has negatively affected the health of minoritized communities via several pathways including health care access, economic, and occupational inequities.

MO345: Clinical Characteristics and Trajectory in a National Cohort of Veterans Treated With Conservative Management Versus Dialysis

Abstract BACKGROUND AND AIMS Within the Veterans Health Administration, the largest integrated healthcare system in the USA, 1.1 million Veterans (16.4%) have been identified as having chronic kidney disease (CKD). Annual spending on US Veterans with non-dialysis dependent CKD is estimated at $19 billion/year, and each year ∼10% of US Veterans with advanced CKD progress to end-stage renal disease (ESRD) requiring renal replacement therapy in the form of dialysis or kidney transplantation. While dialysis has been the dominant treatment paradigm in this population, with ∼22 000 enrolled Veterans receiving dialysis from VA-based dialysis facilities or from VA-contracted community providers, this treatment approach may not offer survival benefit nor improved quality of life in certain subgroups (elderly, multi-morbid). We sought to examine the clinical characteristics of a contemporary cohort of US Veterans with advanced CKD treated with conservative non-dialytic management versus dialysis. METHOD In a national cohort of US Veterans receiving care from the VA healthcare system, we identified patients with advanced CKD, identified as those with ≥ 2 eGFR measurements < 25 mL/min/1.73 m2 separated by ≥ 90 days over the period of 1 October 2010–30 September 2019. Used linked United States Renal Data System and Medicare data, patients were categorized according to (1) receipt of conservative management (CM), defined as those who did not receive dialysis within 2 years of the index eGFR (first eGFR < 25 mL/min/1.73 m2) and (2) receipt of dialysis within 2 years of the index eGFR. We then examined the clinical characteristics and outcome trajectory of those treated with CM versus dialysis, with follow-up through 30 September 2021. RESULTS Among 106 089 advanced CKD patients who met eligibility criteria, 24.6% (N = 26 113) and 75.4% (N = 79 956) were treated with dialysis versus CM, respectively (index eGFR distribution shown in Fig. 1, left panel). In the overall cohort, the mean ± SD age was 73 ± 12 years and 97.4% were men, with a younger age distribution seen in those receiving dialysis versus CM, yet a similar sex distribution across the two treatment groups (Table 1). Across racial groups, there was a greater tendency for Black, Asian, Pacific Islander and Native American Veterans to undergo dialysis versus CM as compared with Veterans of White race. A greater proportion of deaths were observed among Veterans treated with dialysis versus CM (73.2% versus 70.3%, respectively; available follow-up time to censoring or death is shown in Fig. 1, right panel). CONCLUSION In a nationally representative CKD cohort, we observed differences in socio-demographics, including racial background, among patients who were treated with CM versus dialysis. Additionally, death was more frequently observed in those who underwent dialysis versus CM. Further studies are needed to examine the comparative effectiveness of CM versus dialysis transition on CKD outcomes.

Abstract TP415: Coated-Platelet Levels Are Elevated Among Native American Veterans With Vascular Risk Factors and Silent Brain Infarction

Background: Coated-platelets, a subset of procoagulant platelets observed upon dual agonist stimulation with collagen and thrombin, are elevated in patients with incident and recurrent stroke/TIA and mild cognitive impairment. We now report the association between coated-platelets and brain imaging correlates of vascular cognitive impairment in a pilot study of cognitive impairment among Native Americans Veterans. Methods: Coated-platelets, reported as percentage of cells converted to coated-platelets, were assayed in 60 Native American veterans with ≥2 vascular risk factors. The Montreal Cognitive Assessment (MoCA) and the Beck Depression Inventory-II were administered to screen for cognitive impairment and depression. Brain CT or MRI performed within 12 months of enrollment were reviewed for silent brain infarction (SBI), small vessel disease and/or atrophy. SBI was defined as focal, ≥ 3mm, cavitary lesion with T1 hypointensity and T2 hyperintensity features on MRI or hypodense on CT and not associated with stroke history or focal neurologic findings. Differences in mean coated-platelet levels by imaging results were determined using the Kruskal-Wallis test. Results: MoCA scores were abnormal (<26) in 23 of 51 subjects (44%, 95%CI: 30%-59%) after excluding 9 with depression. Brain imaging was available for 36 subjects (97% male, mean age 63 range 50-86). Twelve (33%, 95%CI: 19%-51%) had normal results, 19 (53%, 35%-70%) had small vessel disease and/or atrophy, and 5 (14%, 5%-30%) had SBI. Median coated-platelets were significantly higher among those with SBI (51%, IQR 48%-59%) versus those without SBI having either normal results (36.5%, IQR 30.5%-48.1%) or small vessel disease and/or atrophy (33.6%, IQR 24.4%-47.3%), overall p=0.045. Conclusion: Platelet procoagulant potential is increased among Native American veterans with vascular risk factors and SBI versus those with normal scans or with small vessel disease and/or atrophy. These results suggest a role for coated-platelets as a biomarker of SBI in vascular cognitive impairment, and are consistent with previous findings of increased risk of ischemic stroke among non-Native Americans. Further studies are warranted to confirm these results and explore mechanisms involved.

Native American Vietnam-era Veterans' Access to VA Healthcare: Vulnerability and Resilience in Two Montana Reservation Communities.

As a growing segment of the military, Native Americans are expected to increase enrollment in Department of Veterans Affairs (VA) healthcare. Currently, 20% of Native American veterans are aged 65-74, which means they served during the Vietnam era. This study explores the experiences of rural American Indian veterans from two Montana reservations with accessing VA health services. Utilizing detailed data obtained in focus group and individual interviews, we examine the experiences, attitudes, barriers and needs of rural Vietnam-era veterans. Analyses indicate that while Native American Vietnam-era veterans experienced a poor reception returning to the US after military service, they had more positive receptions in their home reservation communities. However, reintegration was often impeded by poor local opportunity structures and limited resources. As they have aged and turned to the VA for healthcare, these veterans have encountered barriers such as lack of information regarding eligibility and services, qualifying for care, excessive distances to health services, the cost of travel, and poor quality of assistance from VA personnel. Despite variations in their resources, tribal community efforts to honor veterans have begun to facilitate better access to healthcare. Focusing on the roles and importance of place-based resources, this study clarifies challenges and obstacles that Native American Vietnam-era veterans experience with accessing VA health services in rural, reservation communities. Additionally, findings show how tribal efforts are facilitating access as they begin to implement the 2010 agreement between the VA and Indian Health Services to better serve Native veterans.

Abstract TP436: Native American Veterans With Vascular Risk Factors Have High Rates of Vascular Cognitive Impairment

Background: Rates of cardiovascular disease and stroke are elevated in Native Americans, and a greater propensity to develop vascular cognitive impairment (VCI) rather than Alzheimer-type dementia has been inferred, supporting a need for further research in VCI in this population. We determined rates and patterns of memory loss among Native American veterans with multiple vascular risk factors. Methods: Native American veterans ≥50 years old with ≥2 vascular risk factors, including smoking history, hyperlipidemia, diabetes, coronary artery disease, or peripheral arterial disease, were recruited between September 2015 and May 2016. The Montreal Cognitive Assessment (MoCA) and the Beck Depression Inventory-II were used to screen for cognitive impairment and depression. Patients with MoCA scores <26 were referred for imaging studies, memory loss serology, neuropsychiatric testing and clinical assessment by a memory loss physician. Final cognitive status was assigned by blinded adjudication. Results: We recruited 60 Native Americans aged 50-86 (mean±SD: 64±7.1 years); 90% were male, 95% had at least high-school education, and 69% had some college or advanced degrees. Risk factors included hypertension (92%), hyperlipidemia (88%), diabetes (47%), and prior/current smoking (78%). Eight (13%) with severe depression were excluded, leaving 23/51 with abnormal MoCA scores (44%, 95%CI 30%-59%). All with cognitive impairment were male compared to 83% among non-impaired subjects (p=0.059). Fifteen completed additional evaluation for memory loss, including 4/15 with normal MoCA scores who requested evaluation based on symptoms. Results were adjudicated as normal (4), or as having non-amnestic MCI (4), vascular MCI (5), and vascular dementia (2). MoCA correctly identified cognitive status in 86% (Kappa 0.66, 95%CI 0.23-1.00). Conclusions: Native American veterans have high rates of vascular cognitive impairment, which exceed rates of cognitive impairment documented in previously published older non-Native American cohorts. These results highlight the need for improved vascular risk reduction among Native American veterans. Further study is needed to identify ways to improve care in this underserved and understudied population.

<em>Strong Hearts, Wounded Souls</em> Revisited: The Research, the Findings, and Some Observations of Recent Native Veteran Readjustment

Strong Hearts, Wounded Souls RevisitedThe Research, the Findings, and Some Observations of Recent Native Veteran Readjustment Tom Holm (bio) In early 1981 my longtime friend Harold “Hodge” Barse, a Sioux/Wichita/Kiowa who was at the time a readjustment counselor with the Oklahoma City Veterans Administration Outreach program, called to ask me if I knew of any studies of Native American Vietnam veterans. I had to say that I did not know of any. With that telephone call we began an unfunded inquiry into the lives of American Indian Vietnam veterans. It was, in keeping with the foundations of American Indian studies, an activist, academic approach to what we perceived was a largely overlooked and misunderstood group of Indian people who not only deserved recognition for their military service but also merited attention to their specific needs in dealing with their return from a war zone. Both Hodge and I were veterans—he of the army, I of the Marine Corps—and very much aware of the various problems of our veterans and the social, political, and economic conditions they faced upon their homecoming. In particular, Hodge wanted to collect information on our veterans so that he, in turn, could make a case to the Readjustment Counseling Service of the then Veterans Administration to identify and deal with the specific needs of Native American veterans.1 HISTORY OF AND APPROACH TO RESEARCH Very quickly we developed a one-page questionnaire and circulated it among several Native veterans we knew personally. One overwhelming [End Page 118] notion that the few Vietnam veterans we interviewed referred to was that of being recognized for their service. Vietnam was an unpopular war, and many Native Americans opposed it because Indians were subject to the draft and could be sent to war even though the Native population in the United States was extremely poor. Moreover, the U.S. government failed to recognize Indian civil, sovereign, treaty, and human rights.2 Obviously, Native veterans saw their service in a different light, a conception of self that reflected their cultural values as opposed to their political views. They thought of themselves as tribal warriors, an idea that carries a meaning for Native Americans that is very different from its meaning for the larger American society. Perhaps the best way to explain the notion of warriorhood in tribal societies is to look at it in terms of relationships rather than roles. While each American Indian tribe has its own practices, there are some commonalities among many North American tribes. Traditionally, a warrior is part of a community and is not segregated in a base or camp. Members of the community view the warrior as a relative who takes part in battle not only to protect the community but also to restore justice and serve the people in other ways. The warrior may be a scout who finds resources or one who warns the community of a coming attack and becomes the first line of defense against an enemy.3 In 1981, when Hodge contacted me, the way to begin an organization or to ensure the recognition of certain persons or groups among Indian people in western Oklahoma was to hold a powwow. Hodge initiated such an effort at the Wichita tribal grounds near Anadarko, Oklahoma, in order to form the Vietnam Era Veterans Inter-Tribal Association and Gourd Dance Society. This powwow, held in 1981, was the first of a long series of events held in honor of Native Vietnam veterans. I was able to go to Oklahoma and lend my meager assistance in organizing that and a few more subsequent dances. The powwow helped bring together a number of Vietnam veterans to gourd dance and thus participate in a time-honored warriors’ ceremony. According to Kiowa tradition, a lone warrior who was on his journey home from a war party heard some beautiful songs. He investigated the source of the songs and found a red wolf, who taught him the songs and the ceremonies that went with the power or medicine they engendered. The origins of the gourd dance are somewhat controversial. The Kiowa people claim the ceremonies as their own based on this particular piece...

Native American Veterans

Native American Veterans

Health and Ambulatory Care Use Among Native American Veterans

In 1995, the Veterans Health Administration reorganized its health services structure to emphasize ambulatory care. Successful health care planning and improving access to ambulatory care services now depends upon a better understanding of health care needs and outpatient services. Because the veteran population is heterogeneous, it is important to understand the health, access issues, and utilization of ambulatory care services in order to develop effective strategies and interventions to ensure access to and utilization of ambulatory care. Drawing on a focus group methodology with 86 Native American veterans, representing 34 tribes, this study is a qualitative examination of the health, access, use of the Department of Veterans Affairs Health Care services, barriers to health care, and satisfaction with care experienced by Native American veterans. Results reveal problems in accessing care, receiving appropriate care, and coordinating care within the VA health care system. Policy and program recommendations include increasing outreach and education efforts regarding the availability of benefits and services, improving coordination of services between the Indian Health Service and the VA, and reemphasizing the importance of patient-centered care.

Culturally-Appropriate Assessment of PTSD in Native American Veterans: A Poster Presentation

A veteran’s cultural background is relevant to and intertwined with the veteran’s PTSD symptomatology. Researchers at the National Center for Post-Traumatic Stress Disorder have discovered ethnocultural variations in the way veterans communicate symptoms of PTSD and other anxiety and depressive disorders in a clinical setting. See Anthony J. Marsella, Claude Chemtob & Roger Hamada, Ethnocultural Aspects of PTSD in Vietnam War Veterans, 1 NCP (Nat’l Ctr. for Post-Traumatic Stress Disorder), Fall 1990, at 3 (noting research showing “individuals from non-Western cultural traditions often fail to present classical symptoms of [anxiety and depressive disorders]” and, as a result, that “it is quite possible that ethnocultural minority veterans suffering from PTSD and related disorders may be wrongly diagnosed and inappropriately treated”). Researchers have long urged Compensation and Pension examiners in the VA to use culturally-sensitive clinical assessment procedures that fully explore potential cultural aspects of PTSD in a minority veteran. See id. (“Many questions used in clinical tests and interviews . . . are inappropriate in content for assessing ethnocultural minorities and thus do not accurately index problems that may be present.”); see also Terence M. Kean, Danny G. Kaloupek & Frank W. Weathers, Ethnocultural Considerations in the Assessment of PTSD, in ETHNOCULTURAL ASPECTS OF POSTTRAUMATIC STRESS DISORDER: ISSUES, RESEARCH, AND CLINICAL APPLICATIONS 183 (Anthony J. Marsella ed., Am. Psych. Assoc. 1st ed. 1996) (rejecting a single-instrument approach to diagnosing and assessing PTSD across different cultures). Published clinical assessments have demonstrated the kind of complex cultural issues that interact with PTSD and illustrated the kind of comprehensive assessment necessary to fully understand the multifaceted mental health issues of Native American Veterans suffering from PTSD. See, e.g., Jay H. Shore & Spero M. Manson, The American Indian Veteran and Posttraumatic Stress Disorder: A Telehealth Assessment and Formulation, 4 FOCUS 99 (2006). My research is exploring the extent to which the VA is actually implementing culturally-appropriate clinical assessment procedures to assess the severity of PTSD in Native American Veterans for purposes of service-connected disability compensation. Without system-wide implementation of culturally-appropriate assessment procedures, Native American Veterans are likely receiving inaccurate disability ratings, and thus inappropriate disability compensation.

From Mashantucket to Appomattox: The Native American Veterans of Connecticut's Volunteer Regiments and the Union Navy

Due to complex social arrangements among New England Indians and changing perceptions of race, many New Englanders believed that most Indians in the region were “extinct,” while others viewed Indians as “colored men.” At the time of the Civil War, these perceptions allowed many Indian volunteers to cross racial boundaries and serve in both white and colored regiments.

Study Assesses 1-Year Substance Use Remission in Native American Veterans

Study Assesses 1-Year Substance Use Remission in Native American Veterans

Exploring Veteran Identity and Health Services Use among Native American Veterans

The objectives of this study were to describe the military experiences of Native American veterans and to explore how factors related to veteran identity influence their use of health services. Study participants completed a demographic and health questionnaire, followed by participation in a focus group session. The findings revealed that, despite their negative experiences during military service, most participants had a positive veteran identity. Almost 46% of participants reported having a service-related illness or injury. Almost one-third (28.2%) used the Indian Health Service (IHS) exclusively for their health care, followed by those who used both IHS and Veterans Affairs (VA) services (23.5%), followed by VA-only users (21.2%). We conclude that Native American veterans highly identify with their military service but may turn to IHS for their medical care. The data support the current VA policy of strengthening coordination with the IHS to ensure that the medical needs of Native American veterans are addressed.

Perceived barriers to VA mental health care among Upper Midwest American Indian veterans: description and associations.

This community-based study was undertaken to understand why Native-American veterans in the Upper Midwest choose not to use VA mental health services despite high rates of certain psychiatric disorders. A sample consisting of 543 Native-American veterans was obtained using a focused-intensive nonprobability sampling method, structured to over-sample urban and female veterans. Data sources included (1) interview (ie, an open-ended query regarding barriers to VA mental health care), (2) questionnaire (demography, psychiatric rating scales), and (3) computer-based diagnostic questionnaire, the Quick Diagnostic Interview Schedule, and a treatment questionnaire. These data confirmed that Native-American veterans were less apt to employ VA mental health services as compared with other professional and nonprofessional mental health services. Perceived barriers to VA mental health care were coded using a schema developed among Native American and Hispanic VA workers. Types of perceived barriers were qualitatively similar to those obtained from the VA workers, ie, barriers in the VA system, among Native-American veterans themselves, in VA staff members, and among Native American families and communities. Demographic and clinical characteristics among these 543 veterans were not associated with presence-versus-absence of barrier reporting. Among those who did report any barriers, veterans who used more traditional-alternative-complementary (TAC) care reported more barriers than did other veterans. Secondary analysis of those who reported barriers and used TAC revealed that this group had high current rates of Mood Disorder and PTSD symptoms, and high lifetime rates of PTSD and Mood Disorder. Although this latter group had tended to use VA mental health services in the past, they had generally not used them in the last year.

Strong Hearts and Wounded Souls: Native American Veterans of the Vietnam War

Strong Hearts and Wounded Souls: Native American Veterans of the Vietnam War

Strong Hearts, Wounded Souls: Native American Veterans of the Vietnam War.

Strong Hearts, Wounded Souls: Native American Veterans of the Vietnam War.

Strong Hearts, Wounded Souls: Native American Veterans of the Vietnam War

Strong Hearts, Wounded Souls: Native American Veterans of the Vietnam War

Strong hearts, wounded souls: Native American veterans of the Vietnam War

Strong hearts, wounded souls: Native American veterans of the Vietnam War