Rural American Indian Community Research Articles

Integrated Response to Address a Resurgent Syphilis Epidemic in a Rural American Indian Community, Whiteriver, Arizona, January 2022 to June 2023.

The United States has seen a significant rise in syphilis over the past 20 years with a disparate impact on American Indian communities. We conducted a thorough review of the local epidemiology that guided an innovative response to curb the epidemic. We analyzed syphilis data from a hospital in rural Arizona that serves an American Indian population of more than 18,000. Testing data were extracted from 2017 to 2023 with detailed chart reviews of all reactive results since January 2022. Descriptive and comparative statistics were computed using parametric and nonparametric methods where appropriate. Among 5888 tested persons, 555 (9.4%) had reactive results and 277 (4.7%) represented new infections. Among new cases, 151 (54.5%) were female and 55 (19.9%) were reinfections. The annualized incidence rate was 10.0 cases per 1000 persons with peak annualized incidence among women aged 30 to 34 years of 22.6 infections per 1000 persons. During the observation period and after the implementation of programmatic changes in June 2022, there were statistically significant reductions in median time to treatment (-80%), test positivity (-70%), infections (-60%), and no congenital syphilis cases during the observation period. We observed significantly elevated syphilis rates in American Indian/Alaska Native persons compared with the general population. Strategic implementation of new policies and practices led to a measurable and meaningful improvement in several epidemic variables, and our experience may serve as a model to other communities.

Return of Participants' Incidental Genetic Research Findings: Experience from a Case-Control Study of Asthma in an American Indian Community.

The proper communication of clinically actionable findings to participants of genetic research entails important ethical considerations, but has been challenging for a variety of reasons. We document an instance of the return of individual genetic results in the context of a very rural American Indian community, in hopes of providing insight to other investigators about potentially superior or inferior courses of action. This was a case/control study of asthma among 324 pediatric participants. Subsequently, microarray genotype data became available, providing over 2 million variants, incidentally including some conferring risk for conditions for which the American College of Medical Genetics recommends return of results. The study investigators engaged in extensive consultation with the IRB, the tribal government, and local clinicians to better inform our approach. We were able to notify the two participants heterozygous for the one clinically actionable variant identified. One participant welcomed this information and proceeded to obtain further clinical work-up; the other participant declined further follow-up. While demanding considerable time and effort, the return of clinically actionable genetic results is important from both an ethical perspective and to provide an improved trust relationship with the community of research participants.

Potential benefits of expanded palivizumab in American Indian children under the age of 2-years.

Respiratory syncytial virus (RSV) causes a severe respiratory syndrome that disparately impacts American Indian communities. We significantly reduced RSV-related infections and hospitalizations through the expanded the use of palivizumab, an approved yet commonly restricted prophylactic monoclonal therapy.

Method of Developing a Culturally Tailored Diabetes Intervention for American Indians.

American Indians have the highest prevalence of type 2 diabetes compared with any other racial or ethnic group. Developing a culturally tailored diabetes prevention and management intervention is one way to reduce diabetes-related health disparities among American Indian populations. The purpose of this article is to describe our approach for developing a diabetes prevention and management intervention study using Kolb's Experiential Learning Theory as the framework. To ensure the intervention study was culturally meaningful and relevant we used community-based participatory principles by partnering with a team of nurse researchers, tribal diabetes educators, tribal leaders, and tribal community members who were involved in all aspects of the study process. We conducted seven focus groups predominantly in rural American Indian communities in Oklahoma. Using focus group findings, the team collaboratively designed and developed a multi-generational diabetes prevention and management intervention study. The intervention group sessions will focus on ways to prevent and manage diabetes while the control group sessions will focus on general health education topics that have been identified by the team as important and relevant. Family interventions that involve multiple generations and provide emotional and behavioral support to those with type 2 diabetes and family members at risk may provide our best chance at improving diabetes-related outcomes and reducing health disparities in this critical population.

Developing a Response to Secondary Trauma for American Indian and Rural Service Providers.

How can victim service providers, the organizations they work for, and the communities they serve help respond to the issue of occupation-based secondary trauma? Over the last few years, federal agencies in the United States have spent millions in research and programming to answer this important scientific and policy question. The current study builds on this work by describing and evaluating a community-based participatory research project focused on finding manageable, effective, sustainable, and ethical ways to respond to occupation-based secondary trauma in two separate communities: a rural American Indian community, Blackfeet Tribal Nation, and a predominantly white county in Montana, Gallatin County, United States. Findings from evaluation questionnaires (n=178; 80.10% women; 64.60% American Indian; 29.14% White) representing a wide range of occupations document that: (1) the implementation of the project was successful; (2) toolkits created for the project were useful to both individual participants and organizations; (3) training outcomes improved significantly; and (4) findings were consistent across the two different community contexts. Contributions, lessons learned, and future directions are discussed.

Exposure to industrial hog operations and gastrointestinal illness in North Carolina, USA

With 9 million hogs, North Carolina (NC) is the second leading hog producer in the United States. Most hogs are housed at concentrated animal feeding operations (CAFOs), where millions of tons of hog waste can pollute air and water with fecal pathogens that can cause diarrhea, vomiting, and/or nausea (known as acute gastrointestinal illness (AGI)). We used NC's ZIP code-level emergency department (ED) data to calculate rates of AGI ED visits (2016–2019) and swine permit data to estimate hog exposure. Case exposure was estimated as the inverse distances from each hog CAFO to census block centroids, weighting with Gaussian decay and by manure amount per CAFO, then aggregated to ZIP code using population weights. We compared ZIP codes in the upper quartile of hog exposure (“high hog exposed”) to those without hog exposure. Using inverse probability of treatment weighting, we created a control with similar demographics to the high hog exposed population and calculated rate ratios using quasi-Poisson models. We examined effect measure modification of rurality and race using adjusted models. In high hog exposed areas compared to areas without hog exposure, we observed a 11% increase (95% CI: 1.06, 1.17) in AGI rate and 21% increase specifically in rural areas (95% CI: 0.98, 1.43). When restricted to rural areas, we found an increased AGI rate among American Indian (RR = 4.29, 95% CI: 3.69, 4.88) and Black (RR = 1.45, 95% CI: 0.98, 1.91) residents. The association was stronger during the week after heavy rain (RR = 1.41, 95% CI: 1.19, 1.62) and in areas with both poultry and swine CAFOs (RR = 1.52, 95% CI: 1.48, 1.57). Residing near CAFOs may increase rates of AGI ED visits. Hog CAFOs are disproportionally built near rural Black and American Indian communities in NC and are associated with increased AGI most strongly in these populations.

Adaptations of an RCT during COVID: Case Study in one Rural American Indian Community.

The COVID-19 pandemic is global in nature but especially threatens American Indian and Alaska Native (AI/AN) communities due to pre-existing conditions and social determinants of health. Because of the higher risk to AI/AN communities, many tribal nations have been proactive in their policies to keep the virus at bay, including travel restrictions and lockdowns. This affected tribal programs as well as collaborative research projects. One project impacted is the Native CHOICES project, an ongoing randomized controlled trial with an AI/AN community that is focused on the prevention of alcohol-exposed pregnancies. Originally designed to be conducted via in-person motivational interviewing sessions, COVID-19 restrictions precluded the intervention from being delivered in-person as it was designed. The study team received valuable input from the project’s Community Advisory Board (CAB) and community-based staff to establish a feasible and acceptable way of conducting the intervention while respecting tribally-enacted COVID-19 restrictions. The goal of this brief report is to outline not just the process to adapting to COVID-19 but also to provide recommendations for future public health programs, including the ongoing need to consider gaps in access affecting resource-poor settings.

Exposure to Industrial Hog Operations and Gastrointestinal Illness in North Carolina, USA

BACKGROUND AND AIM: With 9 million hogs, North Carolina (NC) is the second leading hog producer in the United States. Most hogs are housed at concentrated animal feeding operations (CAFOs), where millions of tons of hog waste can pollute the air and water with fecal pathogens that can cause diarrhea, vomiting, and/or nausea (known as acute gastrointestinal illness (AGI)). METHODS: We used NC’s ZIP code-level syndromic surveillance system to calculate rates of AGI emergency department (ED) visits during 2016-2019 and swine permit data to estimate hog exposure. Exposure was estimated as the inverse distances from each hog CAFO to census block centroids, weighting with Gaussian decay and by hogs per CAFO, then aggregated to ZIP codes using population weights. We compared ZIP codes in the upper quartile of hog exposure to those without hog exposure. Using inverse probability of treatment weighting, we created a control with similar demographics to the high hog exposed population and calculated rate ratios (RR) using quasi-Poisson models. We examined effect measure modification of rurality and race using adjusted models. RESULTS:Among the 111 high hog exposed ZIP codes, the median number of hogs per ZIP code was 50,022. In high hog exposed areas compared to areas without hog exposure, we observed a 17% increase in AGI rate (95% CI: 1.08, 1.26) and a 24% increase in rural areas (95% CI: 1.04, 1.48). The association was stronger during the weeks after heavy rain (RR=1.54, 95% CI: 1.25, 1.83). When restricted to rural areas, we found an increased AGI rate among American Indian (RR=5.26, 95% CI: 4.60, 5.91) and Black (RR=1.47, 95% CI: 1.04, 1.89) patients. CONCLUSIONS:Residing near hog CAFOs may increase rates of AGI ED visits. Hog CAFOs are disproportionally built near rural Black and American Indian communities in NC and are associated most strongly with increased AGI in these populations. KEYWORDS: Concentrated animal feeding operation (CAFO), animal production, swine, environmental pollution, gastrointestinal illness, waterborne pathogens

Development of a Tribally-led Gardening Curriculum for Indigenous Preschool Children: The FRESH Study

Development of a Tribally-led Gardening Curriculum for Indigenous Preschool Children: The FRESH Study

Cooking for Health: a healthy food budgeting, purchasing, and cooking skills randomized controlled trial to improve diet among American Indians with type 2 diabetes

BackgroundThe prevalence of poor diet quality and type 2 diabetes are exceedingly high in many rural American Indian (AI) communities. Because of limited resources and infrastructure in some communities, implementation of interventions to promote a healthy diet is challenging—which may exacerbate health disparities by region (urban/rural) and ethnicity (AIs/other populations). It is critical to adapt existing evidence-based healthy food budgeting, purchasing, and cooking programs to be relevant to underserved populations with a high burden of diabetes and related complications. The Cooking for Health Study will work in partnership with an AI community in South Dakota to develop a culturally-adapted 12-month distance-learning-based healthy food budgeting, purchasing, and cooking intervention to improve diet among AI adults with type 2 diabetes.MethodsThe study will enroll 165 AIs with physician-diagnosed type 2 diabetes who reside on the reservation. Participants will be randomized to an intervention or control arm. The intervention arm will receive a 12-month distance-learning curriculum adapted from Cooking Matters® that focuses on healthy food budgeting, purchasing, and cooking skills. In-person assessments at baseline, month 6 and month 12 will include completion of the Nutrition Assessment Shared Resources Food Frequency Questionnaire and a survey to assess frequency of healthy and unhealthy food purchases. Primary outcomes of interest are: (1) change in self-reported intake of sugar-sweetened beverages (SSBs); and (2) change in the frequency of healthy and unhealthy food purchases. Secondary outcomes include: (1) change in self-reported food budgeting skills; (2) change in self-reported cooking skills; and (3) a mixed-methods process evaluation to assess intervention reach, fidelity, satisfaction, and dose delivered/received.DiscussionTargeted and sustainable interventions are needed to promote optimal health in rural AI communities. If effective, this intervention will reduce intake of SSBs and the purchase of unhealthy foods; increase the purchase of healthy foods; and improve healthy food budgeting and cooking skills among AIs with type 2 diabetes – a population at high risk of poor health outcomes. This work will help inform future health promotion efforts in resource-limited settings.Trial registrationThis study was registered on ClinicalTrials.gov on October 9, 2018 with Identifier NCT03699709.

The rewarding recovery study: a randomized controlled trial of incentives for alcohol and drug abstinence with a rural American Indian community

AbstractAimsTo test if contingency management (CM) interventions for alcohol and drug abstinence were associated with increased alcohol and drug abstinence among American Indian adults with alcohol dependence who also use drugs.DesignIn this 2 × 2 factorial randomized controlled trial, American Indian adults with alcohol dependence who also used drugs were randomized to four conditions: (1) incentives for submission of urine samples only (control condition), (2) CM incentives for alcohol abstinence, (3) CM incentives for drug abstinence or (4) CM incentives for abstinence from both alcohol and drugs.SettingA Northern Plains Reservation in the United States.ParticipantsA total of 114 American Indian adults aged 35.8 years (standard deviation = 10.4); 49.1% were male.Intervention and comparatorParticipants received incentives if they demonstrated abstinence from alcohol (CM for alcohol, n = 30), abstinence from their most frequently used drug (CM for drugs, n = 27) or abstinence from both alcohol and their most frequently used drug (CM for alcohol and drugs, n = 32) as assessed by urine tests. Controls (n = 25) received incentives for submitting urine samples only.MeasurementsPrimary outcomes were urine ethyl glucuronide (alcohol) and drug tests conducted three times per week during the 12‐week intervention period. Data analyses included listwise deletion and multiple imputation to account for missing data.FindingsThe three CM groups were significantly (P < 0.05) more likely to submit alcohol‐abstinent urine samples compared with the control condition, with odds ratios ranging from 2.4 to 4.8. The CM for drugs (OR = 3.2) and CM for alcohol and drugs (OR = 2.5) were significantly more likely to submit urine samples that indicated drug abstinence, relative to the control condition (P < 0.05). However, these differences were not significant in multiple imputation analyses (P > 0.05).ConclusionsContingency management (CM) incentives for abstinence were associated with increased alcohol abstinence in American Indian adults diagnosed with alcohol dependence who also used drugs, living on a rural reservation. The effect of CM incentives on drug abstinence was inconclusive.

Blood pressure, spirometry, and indoor fine particulate matter in homes heated by wood stoves: pre-intervention results from the EldersAIR randomized trial

Background/Aim: Household air pollution from burning biomass fuels can lead to high concentrations of indoor fine particulate matter (PM2.5) and is associated with many adverse health outcomes. Household heating using wood stoves is common in rural American Indian (AI) communities; however, research on the associations between PM2.5 and health in such communities is limited. Our aims were to assess PM2.5 concentrations and indicators of cardiopulmonary health in older AI adults who use wood stoves for heating, and to evaluate the feasibility of interventions (i.e., education and air filtration) that lower household levels of PM2.5.Methods: EldersAIR was a three-arm pre-post randomized trial in wood stove households from a Northern Rocky Mountain Reservation (n=68) and a Southwestern United States Reservation (n=76). Here, we present pre-intervention concentrations of indoor PM2.5 measured over 2-day sampling periods and measures of peripheral systolic and diastolic blood pressure (SBP; DBP), forced vital capacity (FVC), and forced expiratory volume (FEV1) in older adults.Results: In preliminary analyses, the mean indoor PM2.5 concentration was 38 µg/m3 (standard deviation [sd]=85, median=10) across all homes; 43% of homes had mean PM2.5 concentrations >= 25 µg/m3. Participants were 69 years of age on average (sd=9) with mean body mass index of 30 kg/m2 (sd=6). Participants had mean SBP of 138 mmHg (sd=20) and mean DBP of 77 mmHg (sd=13); 46% had stage-2 hypertension (SBP>=140 or DBP>=90). Mean percent-predicted FVC for participants was 79% (sd=16) and mean percent-predicted FEV1 was 85% (sd=20); 30% had FEV1/FVC ratio < 0.7 or percent-predicted FEV1 < 75%.Conclusions: We observed elevated PM2.5 concentrations inside rural AI homes that used wood stoves for heating. Participants had high SBP and low percent-predicted FVC and FEV1. Our findings highlight the need for interventions that reduce indoor air pollution in an effort to improve health in AI communities.

Barriers to Telemedicine Implementation in Southwest Tribal Communities During COVID‐19

Tribal communities across the United States face significant health and mental health disparities, including rates of suicide that far exceed those of nontribal communities.1 Timely access to health care is limited across most rural areas in the United States, particularly in remote tribal communities.2, 3 It is likely that the COVID-19 pandemic will exacerbate disparities among American Indian tribes, particularly when coupled with existing barriers to access health services.4 In their commentary, Kakol et al (18 April 2020)5 summarized historical and ongoing ramifications of colonization on Southwestern American Indian tribes from an infectious disease perspective, including challenges confronting those communities amidst the COVID-19 pandemic. They comment on the need to expand telehealth to rural Southwest American Indian communities, adding to the burgeoning literature on COVID-19 that emphasizes telehealth approaches, namely telemedicine, as a means of improving access to physical and mental health care, while maintaining social distancing.6-10 Yet, Kakol et al omit the important consideration that broadband Internet access—required to deliver care to patients from a distance—is a barrier to rural patients, no matter how quickly providers are upskilled to deliver it. This is of particular concern in tribal communities. To illustrate this concern, we summarized broadband Internet service data from the 2018 American Community Survey estimates11 for census tracts within the Navajo Nation, the largest American Indian tribe in the United States. We found that 58.1%-87.7% of households in Navajo Nation census tracts reported not having broadband Internet service, compared to 19.6% nationally (Figure 1). Access to broadband Internet service is not only a concern for the Navajo Nation; it is a challenge facing most tribal communities in the United States.12, 13 Even if tribal members can access the Internet at public spaces (eg, local library or school), these locations are far from ideal for telemedicine visits, especially telemental health. The Navajo Nation spans approximately 17,544,500 acres, occupying portions of Arizona, Utah, and New Mexico in the United States (left); and percent of households in Navajo census tracts reporting no access to broadband Internet service (right). Source: Authors’ analysis of data from 2018 American Community Survey 5-year estimates. Without access to technology needed for telemedicine, members of rural American Indian communities are distinctly disadvantaged. Aside from barriers to access, the acceptability and effectiveness of telemedicine among tribal communities must be considered.14 With this in mind, we agree with Kakol et al that telehealth expansion has the potential to improve access to care. However, substantial progress must be made toward increasing broadband Internet service on tribal lands before the potential of telemedicine to serve geographically dispersed but tightly woven communities, such as the Navajo Nation, can be realized.

2189. Improving Surveillance of Rocky Mountain Spotted Fever (RMSF): Implementation of a Multidisciplinary Process

BackgroundSeveral Arizona tribal lands are highly endemic for the potentially deadly tickborne disease Rocky Mountain spotted fever (RMSF). In 2017, state public health officials were concerned with the underreporting of RMSF in our rural American Indian (AI) community. Surveillance of RMSF using serologic methods requires two samples—a baseline (acute) titer and a second (convalescent) titer two to 4 weeks later. Patient return rates are low, leading to poor understanding of disease burden. Our hospital serves a predominantly AI population that is spread across a large geographic area, with limited access to reliable transportation.MethodsWe established a model (Figure 1) for improved RMSF surveillance with a multidisciplinary team comprising clinicians, pharmacists, laboratorians, community health representatives (CHRs), environmental health, clinical care coordinators (CCCs), and public health nurses. The success and sustainability of the system depends on multiple departments sharing the workload.ResultsAs a result of the model, we identified 22 cases of RMSF in 2018, including one death (Figure 2). Testing in the community increased over 9-fold and the total number of titers sent to state lab increased over 13-fold from 2017 to 2018. The system facilitated laboratory follow-up resulting in 61% of samples sent as pairs (acute + convalescent), compared with 36% of samples paired in 2017 (Figure 3).ConclusionThis multidisciplinary process led to improved case identification, improved testing efficiency and sustainable surveillance for RMSF. There was a marked increase in RMSF cases detected at our site, an increase in the number of samples tested and the percent of paired samples obtained during 2018. Beyond this relative improvement, the success rate in paired titers is now the highest in Arizona State, where approximately 40% of samples are paired. There is a need for practical and integrated systems to more accurately test and track cases of RMSF in highly endemic, rural areas. Working together across departments was crucial to address challenges and provide solutions, and led to the success of the model. This process provides a model framework for inter-departmental collaboration and develops a unique system to improve both patient care and education to healthcare workers and the community. Disclosures All authors: No reported disclosures.

A Comparative Analysis of Telephone and In-Person Survey Administration for Public Health Surveillance in Rural American Indian Communities.

Public health surveillance systems suffer from insufficient inclusion of American Indian/Alaska Native (AI/AN) populations. These health surveys have also gravitated to telephone administration because of the rising cost of face-to-face interviewing. Several studies have demonstrated that telephone surveys underrepresent people with low incomes, less educational attainment, and minorities. This study assessed the impact of administration mode upon survey participation in rural AI/AN tribes. Using a modified Behavioral Risk Factor Surveillance System instrument, the Albuquerque Area Southwest Tribal Epidemiology Center partnered with 3 tribes to administer the survey to a target population of 900 AI/AN adults. Half of the sample was assigned to telephone survey administration and the other half was surveyed in-person by trained community interviewers. Significance testing was performed to assess differences in response rates, demographic characteristics, and costs by survey administration type. Several notable differences between the survey administration modes were observed. In-person administration yielded a higher response rate (68.8%) than the telephone survey (35.7%). Likewise, in-person participants were, on average, younger and had lower household incomes and educational attainment than those who completed the survey via telephone. In-person survey administration was also slightly more cost-effective than telephone administration ($192 vs $211 per completed survey) due to the low response rate of telephone administration. The findings from this study have important implications for public health surveillance with rural AI/AN populations, where telephone survey administration is unlikely to yield sufficient coverage of this underserved population. This discovery is particularly disconcerting, given the fact that face-to-face interviewing has largely been replaced by telephone interviewing (and increasingly mobile phones) for public health surveillance in the United States. Without change and innovation, the AI/AN population will continue to lack meaningful health data, further challenging capacity to document and address persistent disparities and inequities witnessed among AI/ANs nationwide.

Process Evaluation Tool Development and Fidelity of Healthy Retail Interventions in American Indian Tribally Owned Convenience Stores: the Tribal Health Resilience in Vulnerable Environments (THRIVE) Study.

ABSTRACTBackgroundThe Tribal Health Resilience in Vulnerable Environments (THRIVE) study aimed to increase healthy food access in 2 rural American Indian communities. The intervention sought to increase fruit and vegetable availability, variety, and convenience through placement, promotion, and pricing of healthy foods and beverages in tribal convenience stores.ObjectiveThe aim of this study was to describe the development and implementation of the study process evaluation tool to assess intervention fidelity as part of this cluster-controlled trial.MethodsEight stores (2 intervention and 2 control stores per Nation) participated in the study, implemented from May 2016 to May 2017. A web-based survey tailored to store layouts and intervention components assessed how often intervention items were available, approximate quantity available, and whether placement of healthier food items and promotional materials were implemented as designed. After pilot testing the survey, tribal staff members implemented it to collect process evaluation data in the 8 stores during a period of 9–12 mo, assessing study implementation and potential changes in control stores.ResultsPromotional materials were available ≥75% of the time for most intervention locations. Fruit availability was similar in Nation A and Nation B intervention stores (79–100% compared with 70–100%), whereas fresh vegetable availability was higher in Nation B compared with Nation A (95–96% compared with 55–75%). Both control stores in Nation A and 1 control store in Nation B had moderate fruit and vegetable availability, ranging from 45% to 52%. No control stores in either Nation used intervention promotional materials.ConclusionsProcess evaluation data indicate that the study was implemented with moderate to high fidelity. The development and implementation of the tool can inform future healthy retail interventions that aim to improve rural and tribal food environments.

Characterizing the local food environment and grocery-store decision making among a large American Indian community in the north-central USA: qualitative results from the Healthy Foods Healthy Families Feasibility Study.

Perceptions of social-contextual food environments and associated factors that influence food purchases are understudied in American Indian (AI) communities. The purpose of the present study was to: (i) understand the perceived local food environment; (ii) investigate social-contextual factors that influence family food-purchasing choices; and (iii) identify diet intervention strategies. This qualitative study consisted of focus groups with primary household shoppers and key-informant interviews with food retailers, local government food assistance programme directors and a dietitian. An inductive, constant comparison approach was used to identify major themes. A large AI reservation community in the north-central USA. Four focus groups (n 31) and seven key-informant interviews were conducted in February and May 2016. Perceptions of both the higher cost of healthy foods and limited access to these foods influenced the types of foods participants purchased. Dependence on government assistance programmes and the timing of benefits also contributed to the types of foods purchased. Participants described purchasing foods based on the dietary needs and preferences of their children. Suggestions for improving the purchase and consumption of healthy foods included: culturally relevant and family-centred cooking classes and workshops focused on monthly food budgeting. Participants also emphasized the importance of involving the entire community in healthy eating initiatives. Cost and access were the major perceived barriers to healthy eating in this large rural AI community. Recommended interventions included: (i) family-friendly and culturally relevant cooking classes; (ii) healthy food-budgeting skills training; and (iii) approaches that engage the entire community.

Culturally-tailored text-messaging intervention for smoking cessation in rural American Indian communities: Rationale, design, and methods.

BackgroundAmerican Indian (AI) and Alaska Native (AN) communities experience disproportionately high rates of tobacco use when compared to the overall U.S. population, especially among rural populations.MethodsWe implemented a single-blind, randomized clinical trial of a text messaging-based smoking cessation intervention through the tobacco quitlines of five states (Alaska, Minnesota, New Mexico, Oklahoma, and Wisconsin) with high percentages of AI residents. We partnered with state quitlines and Optum, a multi-state entity that manages quitlines. Participants who called the quitlines and identified as AI/AN were given the option to enroll in this trial. Upon consent, they were randomly assigned to either the standard quitline program (control) or a program culturally tailored for AI/ANs (intervention), which used a text messaging intervention to encourage smoking cessation. We adapted the text messages based on key informant and focus group input. Baseline data was analyzed for differences across age, sex, and the Fagerström Test for Nicotine Dependence.ResultsWe recruited n = 487 AIs into the trial. Participants had an average age of 41.9 years (SD = 11.7) and 66% were female. The average Fagerström Test for Nicotine Dependence score was 5.38 (SD = 2.37). The intervention and control arms did not significantly differ across any of the baseline characteristics.ConclusionImplementation of this trial illustrated important lessons in adapting, implementing, and evaluating trials in collaboration with AI communities and local and national organizations. This work will inform future efforts to implement culturally-tailored interventions with AI/ANs and advance our knowledge about adapting and implementing smoking cessation interventions.

Collaborative implementation of a community-based exercise intervention with a partnering rural American Indian community.

The prevalence and socioeconomic burden of childhood obesity and diabetes has increased rapidly in the United States in the last 30 years. American Indians have the highest prevalence of type 2 diabetes among newly diagnosed youth in the country. Contributing factors include environmental, behavioral, and genetic components. Some American Indian tribal communities have explored innovative ways to combat this epidemic including collaborations with academic centers on community-based research. From 2012 to 2017, the University of Oklahoma Health Science Center and the Choctaw Nation of Oklahoma partnered on a National Institutes of Health-funded project to determine if financial incentives would elicit an increase in physical activity in Native youth. This was a community-based behavioral intervention for overweight or obese American Indian youth ages 11-20 living in a rural community at risk for developing diabetes. Tribal leaders and staff identified culturally appropriate strategies to aid implementation of the trial in their community. Their identified implementation strategies helped standardize the study in order to maintain study integrity. The mutually agreed strategies included co-review of the study by tribal and University research review boards (but designation of the Choctaw Nation review board as the "Board of Record"), training of community-based staff on research ethics and literacy, standardization of the informed consent process by videotaping all study information, creation of a viable and culturally appropriate timeline for study implementation, adapting tribal wellness center operations to accommodate youth, and development of effective two-way communication through training sessions, on-site coordination, and bi-monthly conference calls. In an effort to partner collectively on a randomized clinical research trial to combat childhood diabetes, tribal leaders and staff implemented strategies that resulted in a culturally appropriate and organized community-based behavioral intervention research project.

Developing a Cultural Immersion Service-Learning Experience for Undergraduate Nursing Students.

Cultural consciousness is a central element of purposeful and appropriate health care delivery. Research suggests that cultural consciousness is strengthened through self-reflection, dialogue about race, and experience within other cultures. Two cohorts of senior-level nursing students participated in a 1-week cultural immersion service-learning (CISL) experience in an isolated, rural American Indian community. Student reflections and White Racial Identity Attitude Scale (WRIAS) data were collected and analyzed. The CISL experience facilitated culturally conscious care in two thirds of the participating nursing students. Differences in WRIAS scores were statistically significant (p < .0001) with an effect size of 1.9. Implementing CISL experiences into the undergraduate curriculum may help nursing students recognize societal privilege and improve cultural consciousness. Recommendations are provided to assist nurse educators to develop partnerships with indigenous nations, which make CISL experiences possible. [J Nurs Educ. 2019;58(2):117-120.].