Native Veterans Research Articles

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.

Rural American Indian and Alaska Native veterans' telemental health: A model of culturally centered care.

American Indian and Alaska Native (AI/AN) veterans living in rural areas have unique health care needs and face numerous barriers to accessing health care services. Among these needs is a disproportionate prevalence of posttraumatic stress disorder and other mental illnesses. Since 2001, 14 rural communities have partnered with the U.S. Department of Veterans Affairs and the Centers for American Indian and Alaska Native Health at the University of Colorado Anschutz Medical Campus to extend telemental health clinics to American Indian veterans. Administrative and, to some extent, clinical considerations of these clinics have been reviewed previously. This paper describes a model of care, evolved over a 14-year period, that weaves together evidence-based Western treatment, traditional Native healing, and rural Native communities into 4 main components: mental health care, technology, care coordination, and cultural facilitation. We delineate improvements to care made by addressing barriers such as system transference, provider-patient trust, and videoconferencing. Similarly, the discussion notes ways that the care model leverages strengths within Native communities, such as social cohesion and spirituality. Future steps include selection of appropriate performance indicators for systematic evaluation. The identification of key constructs of this care model will facilitate comparisons with other models of care in underserved populations with chronic and complex health conditions, and eventually advance the state of care for our warriors. (PsycINFO Database Record

American Akicita: Indigenous American warriors and military service.

Indigenous Americans (i.e., Native/American Indians, AK natives, Pacific Islanders) have consistently volunteered for military service at greater rates than any other ethnic group, including the majority culture, since the early days of the country. This article is an introduction to the special section which includes a number of outstanding papers that provide an innovative and compelling effort to overcome the challenges of casualties from war and render effective and culturally informed care. These manuscripts describe culturally appropriate considerations of suicide (O'Keefe), family involvement and access to care (Whealin), and telehealth for treatment of rural Native veterans (Goss). Challenging and complex treatment needs call for equally mindful and competent approaches. These authors and providers present compelling examples of addressing these needs in working with our Wounded Warriors. (PsycINFO Database Record

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.

<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...

Toward a culturally informed rehabilitation treatment model for American Indian/Alaska Native veterans.

American Indians and Alaska Natives (AI/AN) have a long tradition of military service, allying with Western forces in North America since the 1700s. It is hardly surprising, therefore, that AI/AN veterans experience higher rates of overall disability and service-related disability than veterans of other races and ethnicities. It is not clear, however, that AI/AN veterans with disabilities are receiving effective, culturally informed rehabilitation services. This article examines the incidence of disability among contemporary AI/AN veterans, considers barriers to effective treatment, and points out model programs tailored to the particular needs of this population, with attention to the historical and cultural context of AI/AN military service.

The impact of demographic differences on native veterans’ outpatient service utilization.

Many Native veterans--including American Indian/Alaska Native (AIAN) and Native Hawaiian/Pacific Islanders (NHPI)--have served in the United States Armed Forces. Most of these veterans are eligible for medical care from the Department of Veterans Affairs (VA), but research examining the determinants of their service use is needed to inform policy and allocate appropriate resources for these unique groups. In a retrospective cohort study, we examined the impact of Native veterans' personal demographics on their outpatient utilization of VA-based primary care and mental health services. AIAN (n = 37,687) and NHPI (n = 46,582) veterans were compared with a non-Native reference (N = 262,212) using logistic and binomial regression. AIAN and NHPIs were more likely to be female, report military sexual trauma, and utilize the VA for posttraumatic stress disorder, traumatic brain injury, depression, addiction, anxiety, hypertension, and diabetes care. More AIAN and urban NHPI veterans served in Iraq and Afghanistan, and Native women reported more military sexual trauma than their non-Native counterparts. Primary care and mental health services were associated with race, number of diagnoses, and disability ratings. For mental health services, service era, military sexual trauma, and marital status were related to service utilization. Native veterans' medical need was elevated for primary and mental health care. Rural residence was associated with less mental health use. The findings underscore the need for additional specialized services in rural areas, more targeted outreach to Operation Enduring Freedom/Operation Iraqi Freedom Native veterans, and additional care directed toward Native women's health care needs.

Providing culturally competent services for American Indian and Alaska Native veterans to reduce health care disparities.

We conducted an exploratory study to determine what organizational characteristics predict the provision of culturally competent services for American Indian and Alaska Native (AI/AN) veterans in Department of Veterans Affairs (VA) health facilities. In 2011 to 2012, we adapted the Organizational Readiness to Change Assessment (ORCA) for a survey of 27 VA facilities in the Western Region to assess organizational readiness and capacity to adopt and implement native-specific services and to profile the availability of AI/AN veteran programs and interest in and resources for such programs. Several ORCA subscales (Program Needs, Leader's Practices, and Communication) statistically significantly predicted whether VA staff perceived that their facilities were meeting the needs of AI/AN veterans. However, none predicted greater implementation of native-specific services. Our findings may aid in developing strategies for adopting and implementing promising native-specific programs and services for AI/AN veterans, and may be generalizable for other veteran groups.

Tribal Veterans Representative (TVR) Training Program: The Effect of Community Outreach Workers on American Indian and Alaska Native Veterans Access to and Utilization of the Veterans Health Administration

American Indians and Alaska Natives serve at the highest rate of any US race or ethnic group, yet are the most underserved population of Veterans and do not take advantage of the Department of Veterans Affairs (VA) benefits and services. Barriers to seeking care include stigma, especially for mental health issues; distance to care; and lack of awareness of benefits and services they are entitled to receive. In response to this underutilization of the VA, an innovative program--the Tribal Veterans Representative (TVR) program--was developed within the VA to work with American Indians and Alaska Natives in rural and remote areas. The TVR goes through extensive training every year; is a volunteer, a Veteran and tribal community member who seeks out unenrolled Native Veterans, provides them with information on VA health care services and benefits, and assists them with enrollment paperwork. Being from the community they serve, these outreach workers are able to develop relationships and build rapport and trust with fellow Veterans. In place for over a decade in Montana, this program has enrolled a countless number of Veterans, benefiting not only the individual, but their family and the community as well. Also resulting from this program, are the implementation of Telemental Health Clinics treating Veterans with PTSD, a transportation program helping Veterans get to and from distant VA facilities, a Veteran Resource Center, and a Veteran Tribal Clinic. This program has successfully trained over 800 TVRs, expanded to other parts of the country and into remote areas of Alaska.

Rural Native Veterans in the Veterans Health Administration: Characteristics and Service Utilization Patterns

The Department of Veterans Affairs (VA) and the Indian Health Service (IHS) signed a Memo of Understanding in 2010 to strengthen their partnership in improving health care services for Native veterans, who are disproportionately rural. This paper describes the demographic and service use profile of rural Native veterans who access VA health care. Data were abstracted from the 2008 Veteran Health Administration (VHA) medical dataset, and the characteristics of rural Native veterans were compared to rural non-Native veterans. Rural Native veterans were more rural (41% vs 35%) and more highly rural (8% vs 2%) compared to non-Native veterans. Rural Native veterans were younger, more likely to be female, and earned about the same median income compared to rural non-Native veterans. Although rural Native veterans had fewer diagnoses on average, they were more likely to have served in combat areas and to have higher levels of service-connected disability compared to other rural veterans. Demographic and service-related characteristics of rural Native veterans who accessed VA care differ from those of rural non-Native veterans. Identifying specific health care and service use characteristics will assist in the development of appropriate policy and programs to serve rural Native veterans.

Characteristics of Telemental Health Service Use by American Indian Veterans

This study examined use by American Indian and Alaska Native veterans of services provided by specialty telemental health clinics focused on posttraumatic stress disorder. These clinics offer services via videoconferencing to address challenges faced by rural veterans in accessing care. A retrospective chart and electronic medical record review was conducted for 85 male veterans who used services at two rural telemental health clinics from 2001 through 2006. Service use and other characteristics were documented before and after their initial telemental health intake. After intake, patients' use of any health services (both general medical and mental health services) significantly increased (p<.01), as did the proportion receiving psychotropic medication (p<.01). This first examination of service use by American Indian and Alaska Native veterans at specialty telemental health clinics will help inform research and clinical strategies for improving telemental health for this and other rural populations.

Review of American Indian Veteran Telemental Health

Rural American Indian veterans have unique healthcare needs and face numerous barriers to accessing healthcare services. Over the past decade, the Department of Veterans Affairs in conjunction with the University of Colorado Denver has turned to the promising field of telemental health to develop a series of videoconferencing-based clinics to reach this vulnerable population and improve mental healthcare services. The ongoing development, implementation, and expansion of these clinics have been assessed as part of a program improvement. The outcomes of these assessments have been documented in a series of published articles, controlled studies, program and case reports, and model descriptions. This article summarizes a decade of experience with the American Indian Telemental Health Clinics, the clinic model, and the literature arising from these clinics and presents lessons learned while establishing, maintaining, and evaluating these clinics. The ability to tailor the clinics to individual sites and cultures and to provide various services has been critical to the operation of the clinics. Culturally specific care through culturally knowledgeable providers, onsite tribal outreach workers, and collaboration with community services has proven essential in operating the clinics, as well as building rapport, trust, and engagement with the target patient population. It is hoped that the lessons learned and practices presented here can not only assist others working to improve the care for rural Native veterans but also serve as a model in the use of telemental health services for improving care and access to rural veteran and non-veteran populations.

Do Correlates of Dual Use by American Indian and Alaska Native Veterans Operate Uniformly Across the Veterans Health Administration and the Indian Health Service?

To determine if the combined effects of patient-level (demographic and clinical characteristics) and organizational-level (structure and strategies to improve access) factors are uniformly associated with utilization of Indian Health Service (IHS) and/or Veterans Health Administration (VHA) by American Indian and Alaska Native (AIAN) Veterans to inform policy which promotes dual use. We estimated correlates and compared two separate multilevel logistic regression models of VHA-IHS dual versus IHS-only and VHA-IHS dual versus VHA-only in a sample of 18,892 AIAN Veterans receiving care at 201 VHA and IHS facilities during FY02 and FY03. Demographic, diagnostic, eligibility, and utilization data were drawn from administrative records. A survey of VHA and IHS facilities defined availability of services and strategies to enhance access to healthcare for AIAN Veterans. Facility level strategies that are generally associated with enhancing access to healthcare (e.g., population-based services and programs, transportation or co-location) were not significant factors associated with dual use. In both models the common variable of dual use was related to medical need, defined as the number of diagnoses per patient. Other significant demographic, medical need and organizational factors operated in opposing manners. For instance, age increased the likelihood of dual use versus IHS-only but decreased the likelihood of dual use versus VHA-only. Efforts to enhance access through population-based and consumer-driven strategies may add value but be less important to utilization than availability of healthcare resources needed by this population. Sharing health records and co-management strategies would improve quality of care while policies allow and promote dual use.

Associations Between Race and Ethnicity and Receipt of Advice About Alcohol Use in the Department of Veterans Affairs

This study sought to identify racial and ethnic differences in rates of alcohol-related advice given to veterans treated in Veterans Affairs (VA) facilities. This was a cross-sectional analysis of data from the VA Survey of the Healthcare Experiences of Patients (SHEP). Participants were 255,522 veterans treated in VA ambulatory clinics in fiscal year 2005. SHEP measures included alcohol consumption questions from the Alcohol Use Disorders Identification Test and an item inquiring whether a VA clinician had given advice about drinking. Logistic regression was used to examine relationships between race and ethnicity categories and receipt of alcohol-related advice. Covariate measures included demographic characteristics and physical and mental component summary scores from the Veterans RAND Health Survey (VR-12). Among veterans who consumed any alcohol, compared with veterans from the other racial or ethnic groups, Asian, Native Hawaiian, or Pacific Islander veterans were less likely to be in the medium and highest alcohol consumption categories and non-Hispanic white veterans were less likely to be in the highest alcohol consumption category (p<.001). In a model adjusting for demographic characteristics, physical and mental health status, and alcohol consumption category, among veterans who consumed any alcohol, those who were non-Hispanic black (odds ratio [OR]=1.65, 95% confidence interval [CI]=1.47-1.84), Hispanic (OR=1.56, CI=1.35-1.80), or non-Hispanic American Indian or Alaska Native (OR=1.56, CI=1.06-2.29) were more likely to report receiving alcohol-related advice, compared with non-Hispanic white veterans. The results suggest that veterans from certain minority groups are more likely than white veterans to report receiving alcohol-related advice in the VA, after the model is adjusted for demographic characteristics, health status, and alcohol consumption. Further research is needed to understand the underlying reasons for observed differences in receipt of alcohol-related advice and the potential clinical implications.

Entrance and Exit from the Military

The literature that addresses the reasons for entering military service is limited and generally does not report on the experiences of ethnic minority populations. This article reports on findings from a qualitative research study that examined health utilization and health status for a sample of 86 American Indian and Alaska Native veterans. The study generated data that provide interesting insights about the reasons for entering military service and experiences post discharge for this population. The data indicate that cultural material plays a significant role in the decision to enter the military and in the reentry experience of the veterans who participated in this research study. The analysis supports the proposition that despite the diversity that characterizes the American Indian and Alaska Native experience, there are overarching values and belief systems that are held in common across tribal communities which influence the social construction of life and the interpretation of life events.

Identification of American Indian and Alaska Native Veterans in Administrative Data of the Veterans Health Administration and the Indian Health Service

We sought to determine the extent to which the Indian Health Service (IHS) identified enrollees who also use the Veterans Health Administration (VHA) as veterans. We used a bivariate analysis of administrative data from fiscal years 2002-2003 to study the target population. Of the 32259 IHS enrollees who received care as veterans in the VHA, only 44% were identified by IHS as veterans. IHS data underestimates the number of veterans, and both IHS and VHA need mechanisms to recognize mutual beneficiaries in order to facilitate better coordination of strategic planning and resource sharing among federal health care agencies.

Surgical Morbidity and Mortality among American Indian and Alaska Native Veterans: A Comparative Analysis

Few studies have examined surgical risk factors and outcomes in American Indians and Alaska Natives (AI/ANs). My colleagues and I sought to determine if prevalence of preoperative risk factors for morbidity and mortality differed between male AI/AN and Caucasian surgical patients, and to determine if AI/ANs had an increased risk of surgical morbidity or mortality. We obtained data from the Veterans Affairs National Surgical Quality Improvement Program on major, noncardiac, surgical procedures performed between 1991 and 2002 for all AI/AN men (n = 2,155) and a random sample of Caucasian men (n = 2,264), matched by facility. Chi-square and t-test analyses were used to assess differences in preoperative risk factors between the two groups. Logistic regression was used to determine whether AI/AN race was independently associated with 30-day morbidity (defined as 1 or more of 21 postoperative complications) or 30-day all cause mortality after adjustment for major risk factors. Prevalence of major preoperative risk factors for morbidity and mortality often differed between the groups. Compared with Caucasians, AI/AN race did not predict morbidity (adjusted odds ratio, 0.92; 95% CI, 0.75-1.13), but AI/ANs were at higher risk for 30-day all cause postoperative mortality (adjusted odds ratio, 1.56; 95% CI, 1.04-2.35). Our results add postoperative mortality to health disparities experienced by AI/ANs. Future research should be conducted to identify other factors that contribute to this disparity.