Rural American Indian Reservation Research Articles

Healthy Food Labels Tailored to a High-Risk, Minority Population More Effectively Promote Healthy Choices than Generic Labels.

The decades-long increase in obesity in the US has led to a number of policies aimed at improving diets, which are thought to play a significant role in obesity. Many of these policies seek to influence individuals’ behaviors. Front-of-package labels providing salient, easily interpretable information to consumers have exhibited promise in helping people identify and choose healthier foods. However, behavioral economics may offer an opportunity to enhance label effectiveness. Tailoring labels to high-risk communities, including minority and rural populations, which have higher rates of diet-related diseases than the overall population, may increase the label’s effectiveness. We conducted a choice experiment with supermarket shoppers on a rural American Indian reservation to test labels tailored to the local population relative to a generic label, which had previously been identified as highly effective in the general population. Results show that while the generic label continues to be quite effective in encouraging healthier choices, the label that is tailored to the local community is more effective, resulting in a marked increase in the premium shoppers were willing to pay for a healthy item. Tailoring healthy food labeling systems using insights from behavioral economics may increase their effectiveness.

Feasibility of text messaging to promote child health in a rural community on an American Indian reservation

Objective:This study investigated the feasibility of delivering health-related short text messages to parents with the goal of reducing obesity risk among their children aged 3–5 years.Design:Quasi-experimental design involving one experimental group of 17 parents.Setting:Rural American Indian reservation.Methods:During the 5-week intervention period, parents received 3 topic-related text messages each week for a total of 15 messages. The topics focused on included nutrition, physical activity (PA), sleep, consumption of sugary beverages, TV viewing and screen time. Outcomes included assessments of feasibility including retention rates; delivery, receipt and response to text messages; and programme satisfaction. Pre- to posttest changes in parent knowledge of health behaviours associated with childhood obesity and parent report of these health behaviours in their child were also assessed.Results:A total of 100% (17/17) of the participants completed the study and final assessments. All texts ( n = 289) sent to participants were successfully delivered. Of the 85 texts that requested a response, parents responded to 91% (78/85) by answering the question. All participants reported they found the texts easy to understand. A total of 94% (16/17) of participants reported enjoying the frequency with which they received messages. At the end of the study, parents reported improved overall child health behaviours that approached statistical significance ( p = .051) and parents reported significantly improved behaviours related to PA and sleep ( p = .046). No significant differences were found for changes in parent knowledge.Conclusion:Findings suggest it is feasible to deliver a text messaging-based childhood obesity prevention intervention to parents of young children living on a rural American Indian reservation. Text messages were appreciated by parents and may influence child health behaviours associated with childhood obesity.

Rural Parent Support of Child Health Behavior in the Home Environment: A Qualitative Study on an American Indian Reservation.

Background. Obesity rates are disproportionately high among rural and American Indian (AI) children. Health behaviors contributing to child obesity are influenced by parents at home. Engaging parents remains a challenge, particularly among low-income and ethnic minority families. Aims. The aim of this study was to learn how AI parents living on a rural AI reservation support and engage with their children’s nutrition and physical activity behaviors at home. Methods. Parents with children ages 6 to 12 years living on one, rural AI reservation participated. Focus groups and interviews were conducted, using a 14-question moderator’s guide. A systematic, iterative content analysis was applied to the transcripts. Results. Twenty-five parents (52% AI or Alaska Native) participated in 3 focus groups (n = 17) and interviews (n = 8). Themes related to enhancers included role modeling and whole family and child-initiated activities. Barriers included resources, child safety concerns, driving distances, and competing family priorities. Themes related to strategies for change included opportunities for peer learning from other local families, creating fun, program support for all supplies and incentives, and incorporation of storytelling and multicultural activities. Discussion. This study advances knowledge to promote parental engagement with child health behavior in the home, including unique themes of inclusiveness, culture-focused, and intergenerational activities. Conclusion. Results may inform interventions seeking to engage parents living in rural and AI reservation communities in home-based child behavior change efforts.

Feasibility and outcomes of an out-of-school and home-based obesity prevention pilot study for rural children on an American Indian reservation

BackgroundChildren living in rural areas are at higher risk for obesity compared to urban children, and Native American (NA) children have the highest prevalence of overweight/obesity for all races combined. Out-of-school programs (OOSPs) are a promising setting to improve children’s health. Parents are important in supporting their child’s obesity-related behaviors, yet it remains unclear what combination and dose of parent engagement strategies is feasible and optimal. This study’s primary objective was to assess the feasibility of an OOSP and home-based obesity prevention intervention for rural NA and non-NA children.MethodsThis was an 11-week, two group, randomized feasibility study. Participants were children and their parents at one OOSP on a rural American Indian reservation. Children, ages 6–9, were randomized to receive the Generations Health (GH) intervention or comparison condition. The GH group received daily activities focused on physical activity (PA), nutrition, sleep, and reducing TV/screen time, and frequently engaged parents. The comparison group received usual OOSP activities. To assess intervention feasibility, we measured recruitment and participation rates and program satisfaction. We assessed pre- to posttest changes in body composition, PA and sleep patterns, dietary intake and Healthy Eating Index-2010 (HEI-2010) scores, TV/screen time, and nutrition knowledge. We report recruitment and participation rates as percentages and participants’ program satisfaction as means. Two-tailed paired t tests and 95% confidence intervals were used to detect changes in behavioral and health outcome variables.ResultsForty-six children met age eligibility criteria; following screening, 52% (24/46) met the inclusion criteria and 96% (23/24) were randomized to the study. Overall, 91% of the children participated in the intervention and 100% participated in at least some of the posttest assessments. Parents reported high program satisfaction (mean rating of 4, on a 1–5 scale). Our outcome measure for child adiposity, zBMI, was reduced by 0.15 in the GH group, but increased by 0.13 in the comparison condition. Meaningful changes were evident for total kilocalories, HEI-2010 scores, PA, TV/screen time, and nutrition knowledge.ConclusionsHigh recruitment, participation and program satisfaction and positive health and behavioral outcomes at 11 weeks provide encouraging indications of the feasibility and potential effectiveness of the intervention.Trial registrationISRCTN24274245

Barriers and facilitators to implementation of VA home-based primary care on American Indian reservations: a qualitative multi-case study

BackgroundVeterans Health Affairs (VA) home-based primary care (HBPC) is an evidence-based interdisciplinary approach to non-institutional long-term care that was developed in urban settings to provide longitudinal care for vulnerable older patients. Under the authority of a Memorandum of Understanding between VA and Indian Health Service (IHS) to improve access to healthcare, 14 VA medical centers (VAMC) independently initiated plans to expand HBPC programs to rural American Indian reservations and 12 VAMC successfully implemented programs. The purpose of this study is to describe barriers and facilitators to implementation in rural Native communities with the aim of informing planners and policy-makers for future program expansions.MethodsA qualitative comparative case study approach was used, treating each of the 14 VAMC as a case. Using the Consolidated Framework for Implementation Research (CFIR) to inform an open-ended interview guide, telephone interviews (n = 37) were conducted with HBPC staff and clinicians and local/regional managers, who participated or oversaw implementation. The interviews were transcribed, coded, and then analyzed using CFIR domains and constructs to describe and compare experiences and to identify facilitators, barriers, and adaptations that emerged in common across VAMC and HBPC programs.ResultsThere was considerable variation in local contexts across VAMC. Nevertheless, implementation was typically facilitated by key individuals who were able to build trust and faith in VA healthcare among American Indian communities. Policy promoted clinical collaboration but collaborations generally occurred on an ad hoc basis between VA and IHS clinicians to optimize patient resources. All programs required some adaptations to address barriers in rural areas, such as distances, caseloads, or delays in hiring additional clinicians. VA funding opportunities facilitated expansion and sustainment of these programs.ConclusionsSince program expansion is a responsibility of the HBPC program director, there is little sharing of lessons learned across VA facilities. Opportunities for shared learning would benefit federal healthcare organizations to expand other medical services to additional American Indian communities and other rural and underserved communities, as well as to coordinate with other healthcare organizations. The CFIR structure was an effective analytic tool to compare programs addressing multiple inner and outer settings.

Recruitment for health disparities preventive intervention trials: the early childhood caries collaborating centers.

BackgroundFour trials of interventions designed to prevent early childhood caries are using community-engagement strategies to improve recruitment of low-income, racial/ethnic minority participants. The trials are being implemented by 3 centers funded by the National Institute of Dental and Craniofacial Research and known as the Early Childhood Caries Collaborating Centers (EC4): the Center for Native Oral Health Research at the University of Colorado, the Center to Address Disparities in Children’s Oral Health at the University of California San Francisco, and the Center for Research to Evaluate and Eliminate Dental Disparities at Boston University.Community ContextThe community contexts for the EC4 trials include urban public housing developments, Hispanic communities near the US–Mexican border, and rural American Indian reservations. These communities have a high prevalence of early childhood caries, suggesting the need for effective, culturally acceptable interventions.MethodsEach center’s intervention(s) used community-based participatory research approaches, identified community partners, engaged the community through various means, and developed communication strategies to enhance recruitment.OutcomeAll 3 centers have completed recruitment. Each center implemented several new strategies and approaches to enhance recruitment efforts, such as introducing new communication techniques, using media such as radio and newspapers to spread awareness about the studies, and hosting community gatherings.InterpretationUsing multiple strategies that build trust in the community, are sensitive to cultural norms, and are adaptable to the community environment can enhance recruitment in underserved communities.

A case report of historical trauma among American Indians on a rural Northern Plains reservation.

This case report describes historical trauma on a rural American Indian reservation and outlines participatory action approaches for nurses. The prevalence of historical trauma often goes unnoticed by healthcare professionals because of its multifaceted nature and subsequent lack of provider understanding. Nurses accustomed to looking only for physical and psychosocial signs of trauma may not specifically understand how to align significant historical trauma events with prevention, education, and healthcare delivery. Nursing interventions developed through participatory action and directed at individual, family, and community levels of care are most effective in treating and preventing cumulative effects of historical trauma.

High Food Insecurity and Its Correlates Among Families Living on a Rural American Indian Reservation

We sought to better understand the prevalence and consequences of food insecurity among American Indian families with young children. Parents or caregivers of kindergarten-age children enrolled in the Bright Start study (dyad n=432) living on the Pine Ridge Reservation in South Dakota completed a questionnaire on their child's dietary intake, the home food environment, and food security. We assessed food security with a standard 6-item scale and examined associations of food insecurity with family sociodemographic characteristics, parents' and children's weight, children's dietary patterns, and the home food environment. Almost 40% of families reported experiencing food insecurity. Children from food-insecure households were more likely to eat some less healthful types of foods, including items purchased at convenience stores (P= .002), and food-insecure parents reported experiencing many barriers to accessing healthful food. Food security status was not associated with differences in home food availability or children's or parents' weight status. Food insecurity is prevalent among families living on the Pine Ridge Reservation. Increasing reservation access to food that is high quality, reasonably priced, and healthful should be a public health goal.

HPV infection among rural American Indian women and urban white women in South Dakota: an HPV prevalence study

BackgroundHigh-risk strains of human papillomavirus (HPV) cause cervical cancer. American Indian (AI) women in the Northern Plains of the U.S. have significantly higher incidence and mortality rates for cervical cancer than White women in the same geographical area. We compared HPV prevalence, patterns of HPV types, and infection with multiple HPV types in AI and White women living in South Dakota, U.S.MethodsWe analyzed the HPV status of cervical samples collected in 2006-2008 from women aged 18-65 years who attended two rural AI reservation clinics (n = 235) or an urban clinic in the same area serving mostly White women (n = 246). Data collection occurred before HPV vaccination was available to study participants. HPV DNA was amplified by using the L1 consensus primer system and an HPV Linear Array detection assay to identify HPV types. We used chi-square tests to compare HPV variables, with percentages standardized by age and lifetime number of sexual partners.ResultsCompared to White women, AI women were younger (p = 0.01) and reported more sexual partners (p < 0.001). A lower percentage of AI women tested negative for HPV infection compared to Whites (58% [95% CI = 51-65] vs. 77% [95% CI = 71-82]; p < 0.001), and a higher percentage of AI women were infected by oncogenic types (30% [95% CI = 25-36] vs. 16% [95% CI = 11-21]; p = 0.001). Infections among AI women showed a wider variety and very different pattern of HPV types, including a higher prevalence of mixed HPV infections (19% [95% CI = 26-38] vs. 7% [95% CI = 4-11]; p = 0.001). AI women had a higher percentage of HPV infections that were not preventable by HPV vaccination (32% [95% CI = 26-38] vs. 15% [95% CI = 11-21]; p < 0.001).ConclusionsA higher HPV burden and a different HPV genotyping profile may contribute to the high rate of cervical cancer among AI women.

A Women's Shelter in a Rural American Indian Community

The author presents a case study and personal story about a group of community members initiating a women's shelter in a rural American Indian reservation community. Problems are identified and their resolutions described in organizing a community group, encountering community resistance, locating the shelter, raising funds, and developing procedures for operating the shelter. Lessons learned by the group are provided to illustrate possible solutions to problems that other community groups may encounter when seeking to open a women's shelter in a rural American Indian community.

Risk factors for HPV infection among American Indian and white women in the Northern Plains

Objective American Indian (AI) women living in the Northern Plains have high incidence and mortality rates for cervical cancer. We assessed risk factors for human papillomavirus (HPV) infection among AI and White women. Methods We tested cervical samples for HPV infection obtained from women ages 18–65 years attending 2 rural AI reservation clinics in South Dakota ( n = 235) and an urban clinic serving predominantly White women ( n = 246). Patients self-reported information on HPV risk factors. We used percentages and chi-square tests to compare risk factors, and logistic regression with HPV status as the outcome to quantify the association between HPV and risk factors. Results AI women had more risk factors than White women, including younger age, less education, less vegetable consumption, more sexual partners, younger age at first sexual experience and first pregnancy, and more pregnancies ( p values ≤ 0.003). AI women more often endorsed recreational drug use, history of sexually transmitted diseases, and current smoking; White women reported more alcohol consumption ( p values < 0.001). In multivariate analysis, younger age and current smoking were associated with higher odds of HPV infection in AI women, whereas a higher number of sexual partners was associated with higher odds of HPV infection in White women. Conclusions AI women have a high burden of risk factors for HPV disease, and associations with HPV infection appear to differ by community. Knowledge of specific risk factors in AI populations may provide targets for public health officials to decrease HPV infection and disease.

Cognitive Behavioral Intervention for Trauma in Schools (CBITS): School-based treatment on a rural American Indian reservation

This study examines a pilot school-based treatment program for American Indian adolescents residing on a reservation who presented with symptoms of Posttraumatic Stress Disorder (PTSD) and symptoms of depression. This is the first study directed at treating American Indian children with trauma; seven case studies demonstrate our findings that a manualized cognitive behavior therapy intervention delivered in group format for 10 weeks has potential for helping some children who experience PTSD symptoms and depression. The findings generally replicate previous research conducted with groups of non-Indian adolescents in urban settings. PTSD and depressive symptoms decreased for three of the four students who completed treatment. Directions for future research include the need to understand and control attrition and to address cultural influences, including making adaptations in the cognitive behavioral formulations and techniques regarding feelings as operant behaviors. Results contribute to knowledge of feasibility and acceptability of cultural adaptations of CBT for trauma in an under-served population.

Telepsychiatry with rural American Indians: issues in civil commitments

The use of live interactive videoconferencing to provide psychiatric care, telepsychiatry, has particular relevance for improving mental health treatment to rural American Indian reservations. There is little literature on civil commitments in telepsychiatry and none specifically addressing this topic among American Indians. This article reviews telepsychiatry in the mental health care of American Indians, civil commitments and telepsychiatry in general, and the current state of civil commitments in American Indian communities. We conclude by considering commitment through telepsychiatry in rural reservations and offering guidelines to assist practitioners in navigating this challenging landscape. Civil commitments of American Indian patients residing in rural reservations can be successfully accomplished through videoconferencing by thoughtful and informed clinicians. However, much more work is needed in this area, including research into the cultural attitudes and perspectives towards commitments and further inquiry regarding potential legal precedents, as well as case reports and examples of this work.

Alternative Economic Strategies in Low‐Income Rural Communities: TANF, Labor Migration, and the Case of the Pine Ridge Indian Reservation*

Abstract The premise of current welfare policies is that recipients are avoiding work and that requiring work will end welfare dependency. Unemployment is equated with labor market inexperience and economic inactivity. The Pine Ridge Indian Reservation, a poor rural community with high unemployment, contradicts these assumptions. Many Lakota individuals have off‐reservation wage work experience; there simply are not enough local jobs to absorb their human capital. Lakota households, however, are involved in a complex combination of socially embedded economic activities outside wage work. Imposing the premises of TANF on Pine Ridge results in indirect pressures toward urban migration and cultural assimilation. Furthermore, by imposing rigid notions of work, TANF runs the risk of destroying the economic flexibility that makes survival possible for poor households in Pine Ridge. Welfare and development policies need to reflect the real economies of rural American Indian reservations rather than those of superficially assimilated and economically imagined communities.