Tribal Epidemiology Center Research Articles

Surveillance Methods Used to Detect, Characterize, and Monitor the COVID-19 Pandemic in Rocky Mountain Tribal Communities.

Data were essential to public health decision-making during the COVID-19 pandemic, yet no single data source was adequate for Tribes in Montana and Wyoming. We outlined data access, availability, and limitations for COVID-19 pandemic surveillance response to improve future data exchange. The Rocky Mountain Tribal Epidemiology Center (RMTEC) used various data sources to deliver data on the number of COVID-19 cases, deaths, and vaccinations at local, state, and regional levels to inform Tribes in Montana and Wyoming. RMTEC reviewed state, federal, and public datasets and then attached a score to each dataset for completeness of demographic information, including race, geographic level, and refresh rate. The RMTEC COVID-19 response team shared data weekly on the number of COVID-19 cases, deaths, and vaccinations distributed and the percentage of the population vaccinated with Tribal health departments in Montana and Wyoming. The Indian Health Service Epidemiology Data Mart dataset scored the highest (24 of 30), followed by datasets from Montana (18 of 30) and Wyoming (22 of 30). Publicly available datasets scored low largely due to data aggregation across larger geographic areas and lack of demographic variables. The absence of data on race and ethnicity from publicly available data and lack of access to real-time data limited RMTEC's ability to provide Tribal-specific updates on COVID-19 cases, deaths, and vaccinations to Tribal health departments. RMTEC should be fully funded to provide the necessary resources for data management and the capacity to respond to data requests from Tribal health departments and their programs to address current and future pandemics. Federal and state agencies should also be educated on Tribal Epidemiology Centers' public health authority status to improve access to infectious disease data among those agencies.

Evaluating Inclusiveness in Multi‐Sector Community Health Networks: The Case of Tribal Organizations

Research ObjectiveThere is growing evidence that strong multi‐sector networks of community organizations can reduce health risks and improve outcomes for historically marginalized and underserved populations. Multiple studies of community networks document the advantages of membership inclusiveness and diversity. Over 70% of American Indian and Alaska Native (AIAN) U.S. residents live in urban areas that are not part of tribal lands. Community health networks serving these areas have the potential to engage with tribal organizations in order to better serve AIAN residents, however, the prevalence of tribal organization engagement in these networks is unknown. This study is the first to quantify variation in network inclusiveness regarding tribal organizations across a large national sample of communities, and to identify predictors of inclusion.Study DesignWe used 2018 National Longitudinal Survey of Public Health Systems (NALSYS) data, a nationally‐representative cohort of U.S. public health systems. Tribal engagement was measured as a binary indicator for whether the local public health official reported tribal organization involvement in at least one of 19 essential public health activities. NALSYS data were linked to the American Community Survey, NACCHO's profile survey, Indian Health Services and Tribal Epidemiology Center facility data, and U.S. Census Bureau reservation land data. Social network analysis measures were computed to indicate the extent of tribal organization participation in community networks and to identify what sectors and social services were most likely to engage with tribal organizations. Linear probability models were used to estimate predictors of tribal engagement. Covariates included county‐level variables for AIAN population, distance from a reservation land, presence of a tribal‐serving health facility, and multiple socioeconomic and demographic variables.Population StudiedA stratified random sample of local public health agencies was surveyed with a 71% response rate, yielding 731 respondents that serve approximately 70% of the US population. To account for agencies serving multiple counties (10% of respondents), we disaggregated data to the county‐level (n = 1051).Principal FindingsLocal health officials in 15.7% of counties reported that their networks included tribal organization engagement in at least one public health activity. Among counties with a tribal‐serving health facility located in the region (n = 329), 30.7% of networks included tribal organization engagement. Top activities for engagement with tribal organizations included assessing and prioritizing community health needs, maintaining communication networks, and investigating adverse health events. Tribal organizations had strongest ties with hospitals and community health centers, and organizations that provide housing services, and services for Veterans and people with disabilities. The likelihood of tribal engagement increased significantly with the size of the AIAN population in urban communities (6.2 percentage points, p < 0.001), presence of a tribal‐serving health facility in the region (12.4 percentage points, p < 0.001), and geographic proximity to reservation land (p < 0.05).ConclusionsThe vast majority of community health networks do not report engagement with tribal organizations. Even when tribal‐serving health facilities are present, reported engagement with tribal organizations remains low.Implications for Policy or PracticeLocal public health agencies and their community partners must prioritize efforts to include tribal organizations in their collaborative networks, in order to address persistent AIAN health disparities and emerging health threats such as COVID‐19.Primary Funding SourceThe Robert Wood Johnson Foundation.

Improving Tribal Nation–Specific Mortality Numerators in the South and Eastern Tribes

: The United South and Eastern Tribes, Inc, Tribal Epidemiology Center (TEC) has been conducting a Tribal Nation-specific mortality surveillance project for approximately 13 years. Coded death records are received from states via one of 3 data release methods (open, closed, direct) and matched to Tribal Nation electronic health records. Data quality varies depending on the method of data release. The TEC plans a new method to better identify Tribal Nation decedents and return more robust information to improve Tribal Nation-specific mortality data and strengthen Tribal data sovereignty.

Commentary on Tribal Epidemiology Centers From Tribal Leaders' Perspective.

Commentary on Tribal Epidemiology Centers From Tribal Leaders' Perspective.

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.

Spatiotemporal Analysis of Oklahoma Tobacco Helpline Registrations Using Geoimputation and Joinpoint Analysis.

Tobacco quitlines provide free smoking cessation telephone services to smokers interested in quitting tobacco. We aimed to explore spatial and temporal analyses of registrations to the Oklahoma Tobacco Helpline including those of any racial group and American Indians (AI) from January 1, 2006, to June 30, 2017. This will allow tribal and community organizations, such as the Oklahoma Tribal Epidemiology Center, to better implement and evaluate public health prevention efforts at a smaller geographic area using the larger geographic units that are publicly available. Retrospective, descriptive study. Oklahoma. Registrants to the Oklahoma Tobacco Helpline. To evaluate the spatial distribution of Helpline participants using geoimputation methods and evaluate the presence of time trends measured through annual percent change (APC). We observed increased density of participants in the major population centers, Oklahoma City and Tulsa. Density of AI registrations was higher in the rural areas of Oklahoma where there is a larger tribal presence compared with participants of any racial group. For all racial groups combined, we identified 3 significant trends increasing from July 2008 to March 2009 (APC: 10.9, 95% confidence interval [CI], 0.8-21.9), decreasing from March 2009 to May 2014 (APC: -0.8, 95% CI: -1.1 to -0.4), and increasing from May 2014 to June 2017 (APC: 0.8, 95% CI: 0.0-1.6). The number of AI registrations to the Helpline increased significantly from July 2008 to March 2009 (APC: 12.0, 95% CI: 2.0-22.9) and decreased from March 2009 to June 2014 (APC: -0.7, 95% CI: -1.0 to -0.3). Results of this project will allow the Helpline to efficiently identify geographic areas to increase registrations and reduce commercial tobacco use among the AI population in Oklahoma through existing programs at the Oklahoma Tribal Epidemiology Center.

CDC Partnerships With Tribal Epidemiology Centers to Improve the Health of American Indian and Alaska Native Communities.

CDC Partnerships With Tribal Epidemiology Centers to Improve the Health of American Indian and Alaska Native Communities.

A Spatial Evaluation of Healthy Food Access: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Participants.

It is well known in public health practice that vulnerable populations in rural and inner-city areas may not be able to access healthy foods due to cost, availability, access to transport, and other factors. The Inter Tribal Council of Arizona, Inc (ITCA), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides moderate- and lower-income families with increased access to nutritional information, health care, and healthy foods. ITCA WIC authorizes and enters into contracts with stores that carry a baseline of healthy foods. To use WIC benefits, participants must go to authorized WIC stores where approved healthy foods are available. ITCA Tribal Epidemiology Center developed a methodological framework using Geographic Information Systems to examine WIC authorized stores in 2014 and 2016 to determine whether there were gaps in the store network. To be considered served by the store network, urban WIC participants were required to be within 1 mile and nonurban WIC participants were required to be within 5 miles of a store. We examined whether additional stores could be added to the network to decrease travel distance and travel time in order to further improve access to healthy foods. Between 2014 and 2016, 700 stores were examined and WIC authorized 8 new stores to increase the network; all remote and most rural stores were WIC authorized. In 2014, about 50% of participants met the criteria to be considered served. In 2016, 54% met the criteria, indicating a modest increase in store access for WIC participants. Store network access increased in urban areas from 39% to 41% and from 66% to 74% in nonurban areas between 2014 and 2016. By evaluating the ITCA WIC authorized stores, we note that ITCA increased access to WIC approved healthy foods for WIC participants.

Good Health and Wellness: Measuring Impact Through an Indigenous Lens.

In 2014, the Centers for Disease Control and Prevention (CDC) commissioned the Urban Indian Health Institute (UIHI) to coordinate a multifaceted national evaluation plan for Good Health and Wellness in Indian Country (GHWIC), CDC’s largest investment in chronic disease prevention for American Indians and Alaska Natives (AI/ANs). GHWIC is a collaborative agreement among UIHI, CDC, tribal organizations, and individual tribes. In collaboration, UIHI and CDC drew upon an indigenous framework, prioritizing strength-based approaches for documenting program activities, to develop a 3-tiered evaluation model. The model incorporated locally tailored metrics, adherence to tribal protocols, and cultural priorities. Ultimately, federal requirements and data collection processes were aligned with tribal strengths and bidirectional learning was promoted. We describe how UIHI worked with tribal recipients, tribal health organizations, Tribal Epidemiology Centers, and CDC to develop and implement the model on the basis of an indigenous framework of mutual trust and respect.

The RHINO Community of Practice: Building a Space for Data Users and Enthusiasts in Washington State

ObjectiveTo grow and facilitate a community of syndromic surveillance data users in Washington State, improving and expanding local syndromic practice.IntroductionPrior to June 2016, there were 45 registered users of syndromic surveillance data in Washington State, with 29 (64.4%) representing 5 of Washington’s 35 local health jurisdictions and 16 (35.6%) at the state level. Of those registered users, 9 (8.8%) had logged into ESSENCE at least once in the 6 months before October 2016.In June 2016, the Washington State syndromic surveillance program began accepting Meaningful Use data and sought to increase its user base. To accomplish this, the Washington State Department of Health (WA DOH) designated a staff member to oversee outreach efforts to increase the visibility of syndromic data in the state, including the establishment of a Community of Practice.MethodsThe Washington State syndromic surveillance program—the Rapid Health Information NetwOrk (RHINO)—began the process of stakeholder engagement by delivering a needs assessment to 15 current and potential users of the Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE) platform. The survey assessed interest in participation in a Community of Practice for Washington State syndromic data users, the timing and format for meetings, needs for technical assistance, and topic areas of interest. RHINO then used the survey results to create a bank of topics for Community of Practice calls and develop a strategy for long-term outreach and engagement.In April of 2017, the RHINO team developed a new strategic plan and outlined metrics for evaluating growth and challenges in the program’s outreach efforts, including plans for outreach to novel disciplines like emergency preparedness. These metrics included counts of invitations for speaking engagements, ESSENCE users, onsite ESSENCE trainings and attendees at those trainings, organizations and disciplines represented in the Community of Practice, Community members, and webinars facilitated for the Community. RHINO staff compiled monthly tabulations of these metrics to track progress over the course of the year and aid in adjustments to outreach efforts as necessary.ResultsRHINO received 10 responses to the survey, with 9 respondents from local health jurisdictions and 1 from WA DOH. Respondents indicated particularly strong interest in regular webinars, a database of resources, and live trainings to support syndromic practice in their work. They also expressed concerns about the distance which would be required for in-person meetings.RHINO established that meetings would occur via webinar every other month and held 6 webinars between October 2016 and October 2017 on a broad range of topics including developing syndrome definitions, basic ESSENCE functions, using ESSENCE’s Report Manager tool, monitoring influenza-like-illness in ESSENCE, and using syndromic data for situational surveillance. In addition to the Community of Practice webinars, RHINO staff developed technical guides for both the Washington and National Surveillance Program’s (NSSP) ESSENCE platforms, a handbook for using syndromic surveillance data in Washington State, and a curriculum for onsite ESSENCE training.Between October 2016 and October 2017, RHINO offered 8 onsite ESSENCE trainings for groups of users at the Washington State Department of Health and local health jurisdictions, serving a total of 36 attendees. Over the course of the year, ESSENCE users in Washington State increased to 75, with 40 (53.3%) of them logging into the system at least once over the previous 6 months and 20 (26.7%) listed as “new users” who have not yet activated their accounts. The Community of Practice itself has 86 members representing 16 agencies and 19 disciplines.As RHINO’s profile increased and more potential users became aware of the availability of syndromic data, RHINO began receiving invitations to present for external partners. Between March 2016 and October 2017, RHINO received 8 invitations to present to audiences of potential syndromic data users. These audiences included leadership at the Washington State Department of Health and emergency preparedness and response organizations.In the next year, the program will continue offering data trainings and partner meetings to better serve the needs of both current and potential data users in Washington State. As more jurisdictions begin to have production-quality data, RHINO will continue offering onsite training. RHINO has also built a relationship with the Northwest Tribal Epidemiology Center in Portland, Oregon to begin the process of exploring data sharing with the Tribal Nations and Organizations located within Washington.ConclusionsThrough the development and implementation of a detailed outreach plan, RHINO increased the user base and profile of syndromic surveillance data in Washington State. This work was made possible through the careful construction of strong relationships with new and potential partners and the decision to diversify RHINO’s staff to include members with backgrounds beyond epidemiology.

Addressing Data Inequities in American Indian Communities Through an Environmental Public Health Tracking Pilot Project

National and state surveillance systems identify American Indians/Alaska Natives inconsistently and often inaccurately within their data sets. Consequently, communities may not be represented with data at the level of geography needed. Collecting and presenting environmental and health-related data to the public are done by state Tracking Networks. Great Lakes Inter-Tribal Epidemiology Center (GLITEC) conducted a groundbreaking 2014 Tribal Environmental Health Tracking pilot project that engaged tribes, an urban Indian community, 3 state health departments, a Tribal Epidemiology Center (TEC), and a federal agency. Two other TECs-the Albuquerque Area Southwest Tribal Epidemiology Center (AASTEC) and Northwest Tribal Epidemiology Center (NW EpiCenter)-are now modeling GLITEC's project. They will forge active partnerships with at least one tribe and build relationships with state Tracking programs, explore environmental priorities, identify health outcomes of greatest concern for each community, and determine whether environmental or health inquiries can be addressed through state Tracking data. The Tribal Environmental Health Tracking pilot project provides an example of how state public health Tracking programs can be responsive to data inequities, build relationships between tribes/urban Indian communities, and increase their competency for working with indigenous communities.

Abstract SY14-04: Cancer health disparities in American Indian and Alaskan Native populations

Abstract SY14-04: Cancer health disparities in American Indian and Alaskan Native populations

Oral health beliefs, knowledge, and behaviors in Northern California American Indian and Alaska Native mothers regarding early childhood caries.

To assess the oral health beliefs, knowledge, and behaviors related to early childhood caries (ECC) risk in a convenience sample of American Indian and Alaska Native (AIAN) mothers residing in rural Northern California communities. Fifty-three mothers of young children were recruited from three tribal communities in Northern California with the assistance of the California Rural Indian Health Board, Inc. and its California Tribal Epidemiology Center and Dental Support Center. Trained study staff administered questionnaires to obtain basic socio-demographic information, to survey participants on their oral health beliefs, knowledge, and behaviors as related to ECC risk, and to identify possible barriers to their accessing professional oral health care. Analyses of covariance were used to explore associations between socio-demographic indicators and oral health behaviors, after controlling for knowledge, beliefs and barriers to care. Overall, 53 percent of participants reported their oral health as "fair" or "poor." Mothers' education (high) and being employed were positively associated with better oral health behavior scores. Additionally, 72 percent of mothers reported having one or more barriers to oral health care including access. There was a significant relation (P = 0.03) between high number of reported barriers to oral health care and low oral health behavior scores. Despite generally high-level oral health knowledge, perceptions of self and child oral health remains low in this sample of AIAN mothers. Factors identified as being associated with oral health behaviors in this sample were similar to those found in other health disparities populations.

Partnering with American Indian communities in health using methods of strategic collaboration.

The Association for Prevention Teaching and Research (APTR) sponsored six regional workshops in 2010 on community engagement and community-engaged research. One of the six workshops was a collaborative effort between the Great Plains Tribal Chairman's Health Board (GPTCHB)-Northern Plains Tribal Epidemiology Center and the College of Public Health at the University of Nebraska Medical Center (UNMC-COPH). To create a meaningful and dynamic forum for the exchange of ideas and co-learning between researchers from urban, tribal and nontribal communities and to build the groundwork for development of sustainable partnerships between researchers and American Indian (AI) communities to eliminate health disparities. To enhance meaningful community engagement, we utilized methods of Strategic Collaboration using the Appreciative Inquiry, 4D Change Process Model and designed several interactive group activities including Collaborative Learning and Understanding Exercises (CLUE) and the Research Café. The key themes that emerged from the interactive sessions stressed the importance of building relationships and trust; mutual use and sharing of data; and acquiring knowledge, skills, and abilities to enable sustainable research partnerships with AI communitiesConclusions: Innovative, dynamic, and strategic collaborative methods of Appreciative Inquiry and the World Café can served to engage people in a constructive dialogue to create a shared vision and plan for more meaningful research partnerships based on principles of equity and social justice, essential for the elimination of health disparities. These collaborative methods can be replicated and adapted in diverse communities, locally, nationally, and globally.

APA, AACAP Suggest Ways to Reduce High Suicide Rates in Native Americans

Back to table of contents Previous article Next article Government NewsFull AccessAPA, AACAP Suggest Ways to Reduce High Suicide Rates in Native AmericansEve BenderEve BenderSearch for more papers by this authorPublished Online:16 Jun 2006https://doi.org/10.1176/pn.41.12.0006aThere is a critical need for suicide screening and prevention efforts among American Indian youth, according to APA and the American Academy of Child and Adolescent Psychiatry (AACAP). The two organizations made this point in a joint statement submitted to the Senate Indian Affairs Committee for a hearing in May.The hearing was held to bring attention to the high rate of suicide among American-Indian youth and to highlight proposed solutions to the problem. According to the Indian Health Service, 33.9 per 100,000 American-Indian youth commit suicide each year, which is 2.5 times the national rate for all youth.Government officials, mental health care advocates, and psychiatric and mental health professionals were some of those who testified at the hearing.In the statement, APA and AACAP endorsed a series of recommendations to improve access to mental health treatment in American Indian communities, increase funding for programs that provide screening and treatment services, and propel legislation to ameliorate the shortage of child and adolescent mental health professionals.Suicide is the second leading cause of death among Indian-American youth, according to the statement, and risk factors for American Indian youth include substance abuse, a lack of social support, and depression.“American-Indian youth are also at higher risk of suicide due to intergenerational trauma, including loss of parents and relatives to suicide, which adds to a lack of social support in many Indian American communities for youth,” the statement read.Unique among American-Indian communities are barriers to treatment arising in part from the separation of health services from state and federal programs. Such separation “often prevents Native Americans from receiving comprehensive, integrated treatment for mental health, alcoholism, substance abuse, and other general medical care.”In addition, APA and AACAP proclaimed the nationwide shortage of child and adolescent psychiatrists and other mental health professionals a“ severe” problem for American Indians and called for the enactment of the Child Health Care Crisis Relief Act (S 537/HR 1106), which seeks to increase the number of professionals providing mental health treatment to children and adolescents.Since a number of Indian reservations are located in geographically remote areas, some Indian families must travel for hours to access mental health treatment, the statement pointed out. However, the situation may soon improve: APA and AACAP endorsed the Senate passage of the Indian Youth Telemental Health Demonstration Act in May. The bill authorizes $1.5 million each year from 2007 to 2010 to use electronic technology to support long-distance mental health care aimed at preventing suicides among American Indian youth.APA and AACAP made a number of recommendations in the joint statement to reduce the prevalence of suicide among American Indian youth. Among them:Increase appropriations for the Indian Health Service including those for loan re-payment programs for health professionals, Tribal Epidemiology Centers, and suicide prevention.Create school-based mental health programs in American Indian communities.Expand community-based systems of care in American Indian communities in educational settings, the child welfare system, and the juvenile justice system, for instance.The APA-AACAP statement is posted at<www.psych.org/members/download.cfm?file=1216>.▪ ISSUES NewArchived

Tribal Epidemiology Centers: A New Avenue to Enhance and Monitor Health in American Indian and Alaska Native Communities

Tribal Epidemiology Centers: A New Avenue to Enhance and Monitor Health in American Indian and Alaska Native Communities