Tribal Settings Research Articles

PUBLIC HEALTH RESPONSES TO DEMENTIA IN RURAL AND TRIBAL AREAS: BOLD AND BEYOND

Abstract Rural and tribal communities have unique characteristics specific to their geographical location and cultures that can influence how disease prevention and health promotion programs are delivered in these areas. Public health officials may need to adapt traditional strategies to improve uptake, effectiveness, and reach in rural and tribal settings. CDC’s Healthy Brain Initiative (HBI) Road Map Series identifies priority actions public health agencies can take to promote brain health and support caregivers. The Road Map Series includes one designed for local and state agencies and another for Indian Country. CDC’s Building Our Largest Dementia (BOLD) Infrastructure for Alzheimer’s Public Health Program awardees carry out Road Map actions to develop and strengthen the public health infrastructure. This session will illustrate how public health entities have developed dementia resources within rural and tribal areas in their jurisdictions. Four states – Maine, Mississippi, Utah, and Washington – and a tribal board – the Northwest Portland Area Indian Health Board – will be presenters. They will characterize their population, identify the dementia programs and services they offer, describe challenges faced, and discuss the impact of rurality and tribes on their approach to service delivery and outreach. Presenters will discuss resources and collaborative approaches used to ensure success. Together, these presentations will highlight public health strategies that have been effective at supporting brain health in all communities across the lifespan.

The Expanding Role of Public Libraries in Tribal Settings: From Traditional Services to (Advanced) Digital Skills, Citizen Engagement, and Innovation

ABSTRACT This paper presents a case study of Ignacio Community Library (ICL) on the Southern Ute Indian Tribe Reservation (Colorado) to show how public libraries in tribal settings currently contribute to their communities and whether such context influences these contributions. Based on existing literature and a dozen in-depth interviews, we find that ICL meets various needs and empowers citizens with (advanced) digital skills to use (emerging) technologies for specific purposes and also to innovate. Further, ICL expands opportunities for active citizen engagement in public affairs. These contributions align with local priorities and demonstrate how unique local circumstances affect specific ICL’s contributions.

Managing an adolescent with Type 1 Diabetes and socioeconomic deprivation in a remote primary care setting — Ethical challenges

This case study discusses the ethical challenges encountered by a primary care team in managing a 17-year-old girl with Type 1 diabetes in a socio-economically deprived tribal area. The case highlights critical issues such as justice in access to essential medicines, ethical dilemmas arising from complex family dynamics, and systemic failures within the public health system. By examining these challenges, this case study underscores the importance of addressing broader social determinants of health to ensure just and effective healthcare delivery in rural and tribal settings.

Establishing palliative care in tribal and rural Indian setting: A participatory action research approach.

e24085 Background: We established a palliative care center in the tribal area of Santhal Pargana, India, under a tertiary care facility, as a crucial step in addressing the palliative needs of oncology patients. This study assesses the center's inaugural year, focusing on referral patterns, morphine consumption, and pain management. Methods: Data from all patients visiting the palliative care outpatient department (OPD) in 2023 were prospectively collected and analyzed. The study focused on key palliative care indicators, including morphine consumption, patient referrals, and the mean Numeric Rating Scale (NRS) pain score after initial consultation. The PAR approach was utilized to tailor services to the community's needs. Results: The center observed an increase in patient referrals, from 8 new patients in January to 19 by December. The patient demographic primarily comprised individuals with head and neck cancer (43%), followed by breast cancer (28%) and gall bladder cancer (12%), alongside other types such as cervix, sarcomas, lung, and adult hematolymphoid malignancies. Bone metastasis was present in 46 (55.4%) patients at initial presentation. Morphine consumption demonstrated a notable rise, from 840 mg in May to 2860 mg in December, totaling 9800 mg for the year. The mean NRS pain score improved significantly from 6.5 in January to 4.3 post-initial consultation. The center maintained an overall median of 3 consultations per patient, and bereavement support was provided to 13 (15.7%) patients. Conclusions: The integration of the Participatory Action Research approach, specifically the CTC-5, was instrumental in the successful initiation and expansion of palliative care services within the center. The structured training, mentorship, and organizational restructuring, facilitated by the program, were crucial in establishing a modest palliative care infrastructure. This comprehensive approach not only enhanced care delivery but also ensured the sustainability and adaptability of palliative services, effectively addressing the gap in palliative care in rural, tribal settings.

Comparison of household double burden of malnutrition among mother-child dyads in different settings in Maharashtra

ABSTRACT The study aimed to assess and compare the household double burden of malnutrition among mother-child dyads in different settings in Maharashtra. A cross-sectional pilot survey was perforamed among 295 randomly selected mother-child dyads from 22 anganwadis. Urban households from three wards in Pune city, six villages from two tehsils in rural Pune, and ten villaages from the tribal district of Palghar were randomly selected. Distribution of wasting was ‘very-high’ (37.7%) in the tribal settings, followed by urban settings which recorded ‘high’ wasting (13.7%) as per the severity threshold. Over 37% of the children manifested overweight and obesity. Stunting was high in urban areas (49.3%), while underweight was high in the tribal regions (>55.7%). Overweight and obesity among mothers in the urban setting (82%) was twice compared to the rural (42%). The overall prevalence of double burden of malnutrition was 19.7%. The double burden of malnutrition at the household level was high (46%) in urban households followed by rural (17%) and tribal settings (5.7%). Double-duty strategies at the community level are the need of the hour to curb the rising double burden across settings.

IJCM_30A: A mixed methods study to assess the contributory factors to anaemia among adolescent girls studying in tribal schools in a rural area of Maharashtra

Background: Anaemia is prevalent globally, notably in marginalized adolescent girls. NFHS-5 reports 59.1% anaemia in Indian adolescent girls. Tribal communities face unique health challenges due to their sociocultural dynamics. The national program for anaemia addresses this, but its implementation in contexts like tribal areas is unexplored. This study integrates quantitative and qualitative data for a thorough understanding of anaemia and its control in tribal settings. Objectives: 1. To estimate the prevalence of anaemia in tribal adolescent girls 2. To explore the awareness of anaemia in tribal adolescent girls 3. To understand the challenges in the implementation of an anaemia control program in a tribal setting Methodology: This 6-month mixed methods study assessed anaemia prevalence among adolescent girls in tribal schools. Using complete enumeration, a 200-sample size was determined, with obtained informed consent and assent. Adolescent girls were administered a questionnaire in their local language to collect information on their socio-demographic status and anaemia-related habits like diet and handwashing among others. Haemoglobin levels were measured using a digital haemoglobinometer. Focus Group Discussions with willing girls explored their understanding of anaemia, its causes and complications. Forced field analysis for ASHA and Anganwadi workers and certain Key Informant Interviews were conducted. Data was collected until saturation. Ethical approval with confidentiality was ensured. Results: The prevalence of anaemia was 70%, indicating a severe public health concern. Among these, 57.1% had mild, 34.3% had moderate, and 8.6% had severe anaemia. Anaemia in girls was statistically associated with specific food groups and habits. Low awareness of anaemia and operational issues in the control program were also identified. Conclusion: To enhance adolescent awareness of anaemia, efforts to improve their understanding of the condition and its impact are necessary. This research is vital for informing policymakers and health practitioners in refining interventions for this specific demographic in Maharashtra.

Prevalence and Pattern of Morbidity, Febrile Illness, and Treatment-Seeking Behavior in a Tribal-Dominated District in Odisha, India: An Observational Study.

Background Tribal populations constitute a major portion of India's total population, especially in the eastern and northeastern states. We lack comprehensive information on the community burden of general morbidity and febrile illness in tribal population-dominated areas, which is quite essential for the microplanning of healthcare expenditure and implementation. This study aimed to provide evidence on the prevalence and pattern of general morbidity and febrile illness at the community level as well as the treatment-seeking behaviour in a tribal-dominated area. Methods The study was undertaken as an observational study in the community setting; looking into seasonal cross-sectional evidence on period prevalence (two weeks) of morbidity and qualitative/semiquantitative information on treatment-seeking behaviour of the selected community during 2012 and 2013. Result This study involved 5541, 5482, and 5638 individuals during the rainy season 2012,winter 2012-13, and rainy season 2013 seasons, respectively, from 25 tribal villages of Odisha, India. A period prevalence (two weeks) of overall morbidities was shown to be 27.28% and 28.9% during the rainy seasons of 2012 and 2013, respectively, of which 13% and 11.5%, respectively, were febrile, with low prevalence(6.44% overall morbidity and 1.81% febrile illness) in the winter of 2012-13. It indicated inadequacy in skills of the village-level health staff, monitoring of supplies/logistics, and population awareness for early reporting of fever to healthcare providers at the community level. Conclusion The evidence provided by the study would be helpful in making public health plans in tribal settings and also highlighted the opportunity to improve tribal health status through community awareness, especially in areas and populations with limited health access.

MAKING OLDER ADULT FALL PREVENTION A ROUTINE PART OF HEALTHCARE IN TRIBAL CLINICAL SETTINGS

Abstract Over one-third of American Indian and Alaska Native (AI/AN) elders (age 65+) report falling annually. This percentage is higher compared to other race/ethnic groups except for White non-Hispanic older adults. CDC’s Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative provides guidance for making elder fall prevention a routine part of clinical care. The presentation will describe a survey of healthcare providers serving AI/AN populations to gauge their readiness to adopt STEADI. Additionally, it will focus on a culturally informed approach to implementing STEADI within tribal settings. The National Network of Public Health Institutes and Seven Directions, A Center for Indigenous Public Health, surveyed a convenient sample of healthcare providers in clinics serving AI/AN patients to assess providers’ knowledge and acceptability of fall prevention best practices, efforts to prevent falls, and receptiveness to receiving fall prevention training and support. The final sample included 94 healthcare providers from 27 clinics. Less than half of those surveyed reported screening elders for fall risk. Only 22% were familiar with STEADI. Most (84%) providers were willing to take part in fall prevention with additional training. Based on these findings CDC is funding two tribes to use an indigenous evaluation approach to improve their tribal health center’s elder fall prevention capacity through evidence-based clinical and clinical-community linked strategies. Results from these activities will be used to outline a best practices guide focused on coordinated care for fall prevention and tailored to the varied environments, governments, cultures, and capacity for public health action in tribal health centers.

Challenges in screening for sickle cell disease among newborns from the tribal region of Palghar, Maharashtra during the COVID-19 pandemic.

Despite several adversities imposed by the COVID-19 pandemic, it was crucial to sustain research having public health relevance such as investigations around sickle cell disease (SCD). Against this background, an ongoing ICMR-multicentric study for newborn screening of SCD in the tribal population at Model Rural Health Research Unit (MRHRU-Dahanu) in Palghar District, Maharashtra constituted the current study setting. This was a descriptive study wherein, certain measures were undertaken and strategies were developed in view of the challenges in newborn screening for SCD due to the COVID-19 pandemic during December 2019-September 2021 at Sub District Hospital, MRHRU-Dahanu. During the onset of the pandemic, (December 2019-March 2020), the follow up was possible in 26.7 per cent (20/75) of the newborns. Subsequently, challenges such as travel restrictions, fear of COVID-19, shortage of staff were experienced with respect to enrolment and follow up visits. After implementing certain pragmatic strategies (ASHA involvement, usage of virtual platform and flexible visits), follow up rate increased to 47.5 per cent (66/139) between July 2020-April 2021 (post first lockdown) and to 66 per cent (65/98) during the second wave (May 2021-August 2021). The study emphasizes the importance of network building, use of virtual platform and engaging health workers in tribal settings. Such pragmatic approaches have the potential to pave a path for further implementation research involving specific interventions to improve health outcomes in tribal settings.

Personality predictors for emotional intelligence: A comparative study of urban, rural and tribal areas

The study's objective was to compare the personality predictors among teenagers for emotional intelligence from urban, rural, and tribal settings. The sample consisted of 600 teenagers (300 boys and 300 girls) aged 13 to 17 who were chosen at random from a various Government High Schools in the districts of Karnataka. The Multi-Dimensional Assessment of Personality and the Mangal & Shubhramangal Emotional Intelligence Inventory were administered for teenagers. Data analysis was done using regression analysis. The findings showed that out of the twenty personality traits—five in urban adolescents, three in rural adolescents, and two in tribal adolescents—best predicted emotional intelligence. The study has unequivocally demonstrated that teenagers from urban, rural, and tribal backgrounds have varied personality determinants for emotional intelligence.

Association of Substance Abuse and Tuberculosis among Tribes: Study in Three Tribal Settings of Kerala, India

Substance abuse such as alcohol consumption and smoking serve as profound indicators for Tuberculosis (TB). Tribes in rural India are the vulnerable population for various diseases and substance abuse is more prevalent among them. Very few studies have been conducted to find the substance abuse and its association with TB among tribes in Kerala. Hence, we sought to understand the prevalence of substance abuse among tribes, and its association with chest symptomatic cases and cases with history of TB. This study aimed to identify the predictors of negative social behaviours among tribes and their association with chest symptomatic cases and history of TB. It was part of a collaborative research program to estimate the burden of TB amongst tribal groups, by ICMR, NIRT, Chennai and SRM University, Kancheepuram and Population Research Centre, Kerala conducted in 2018. This article presents the prevalence of substance abuse (tobacco and alcohol) among tribes, and its association with chest symptomatic cases and cases with history of TB. The study also tried to find out the predictors of substance use among tribes. Among 2609 tribes interviewed, 14.6% were smokers, 47 percent were used smokeless tobacco and 29% were consumed alcohol and only 20 respondents reported using drugs. Significant association of chest symptoms and TB history status with district, category of tribe, age, education, marital status, and nutrition are observed in the study. Chest symptomatic cases and those who had the history of TB had a highly significant association with use of smokeless tobacco and smoking. However, the study could not find a significant difference between those consuming alcohols. The predictors of substance abuse were found to be in higher age groups, low education, being in the low socio-economic profile and in the low BMI. To attain health goals like zero TB, control of substance use is an essential component especially among tribal communities. This study highlights the importance of education and better living conditions in reducing negative health behaviours among tribes.

Caring Texts, a strength-based, suicide prevention trial in 5 native communities: Research design and methods

BackgroundDespite their intrinsic strengths and resilience, some American Indian and Alaska Native (AI/AN) communities experience among the highest rates of suicide of any racial and ethnic group. Caring Contacts is one of the only interventions shown to reduce suicide in clinical trials, but it has not been tested in AI/AN settings. ObjectiveTo compare the effectiveness of Enhanced Usual Care (control) to Enhanced Usual Care augmented with a culturally adapted version of Caring Contacts (intervention) for reducing suicidal ideation, suicide attempts, and suicide-related hospitalizations. MethodsWe are implementing a single blind randomized controlled trial of Caring Contacts in five AI/AN communities across the country (South Dakota, Montana, Oklahoma, and Alaska). Eligible participants have to be (1) actively suicidal or have made a suicide attempt within the past year; (2) at least 18 years of age; (3) AI/AN; (4) able to speak and read English; (5) able to participate voluntarily; (6) willing to be contacted by text, email or postal mail; and (7) able to provide consent. Following consent and baseline assessment, participants are randomized to receive either Enhanced Usual Care alone, or Enhanced Usual Care with 12 months (25 messages) of culturally adapted Caring Contacts. Follow-up assessments are conducted at 12 and 18 months. ConclusionsIf effective, this study of Caring Contacts will inform programs to reduce suicide in the study communities as well as inform future research on Caring Contacts in other tribal settings. Modifications to continue the trial during the COVID-19 pandemic are discussed.Clinical Trials Registration: NCT02825771.

Cost of Illness Due to Severe Enteric Fever in India.

Background Lack of robust data on economic burden due to enteric fever in India has made decision making on typhoid vaccination a challenge. Surveillance for Enteric Fever network was established to address gaps in typhoid disease and economic burden.MethodsPatients hospitalized with blood culture-confirmed enteric fever and nontraumatic ileal perforation were identified at 14 hospitals. These sites represent urban referral hospitals (tier 3) and smaller hospitals in urban slums, remote rural, and tribal settings (tier 2). Cost of illness and productivity loss data from onset to 28 days after discharge from hospital were collected using a structured questionnaire. The direct and indirect costs of an illness episode were analyzed by type of setting.ResultsIn total, 274 patients from tier 2 surveillance, 891 patients from tier 3 surveillance, and 110 ileal perforation patients provided the cost of illness data. The mean direct cost of severe enteric fever was US$119.1 (95% confidence interval [CI], US$85.8–152.4) in tier 2 and US$405.7 (95% CI, 366.9–444.4) in tier 3; 16.9% of patients in tier 3 experienced catastrophic expenditure.ConclusionsThe cost of treating enteric fever is considerable and likely to increase with emerging antimicrobial resistance. Equitable preventive strategies are urgently needed.

Cultivating Healthy Governance in Rural Programs.

Cultivating Healthy Governance in Rural Programs.

Integration of the preventive medicine specialty in the rural and Tribal public health workforce

The majority of the U.S. American Indian and Alaska Native (AI/AN) population live in rural areas, and are thus disproportionately affected by rural health issues. In addition, the AI/AN population has unique health characteristics resulting from a distinct cultural and sociopolitical history. A public health approach to both rural and Tribal health should include the medical specialty of preventive medicine, a unique physician specialty that combines both direct patient care and public health skills. To best prepare preventive medicine physicians for rural and Tribal practice, medical schools could recruit students from rural and Tribal areas and encourage them to pursue the specialty of preventive medicine. Additionally, preventive medicine residency training programs could establish clinical and public health practicum rotations in rural and Tribal areas, and develop curricula that address rural and Tribal health issues. Currently very few preventive medicine residency programs expressly state a mission to train physicians in rural or Tribal settings.

Natural resource valuation with a tribal perspective: a case study of the Penobscot Nation

ABSTRACTThe unique settings of tribal lands and preferences of tribal members can complicate the effective application of standard natural resource use valuation tools within these tribal settings. We present a study which utilised referendum format contingent valuation methods to value foregone tribal use of the dioxin-contaminated Penobscot River in Maine. The Penobscot Nation’s prior experience in using referendums to evaluate cash settlement offers provides a unique setting for this application. The valuation responses pass a scope test and are consistent with a priori expectations of economic theory as well as individual attitudes and beliefs. Implicit discount rates based on the valuation of two clean-up periods are plausible. The response model indicates that cultural motives are a significant basis of foregone use values. While each tribal setting presents unique characteristics and challenges, the presented application demonstrates how carefully applied standard valuation tools, when appropriately designed to account for and incorporate tribal history, settings, and perspective, can yield defensible estimates of resource valuation.

Assessment of Growth Monitoring and Promotion Programme of the Integrated Child Development Services in Maharashtra

Growth Monitoring and Promotion (GMP) Programme is primarily a preventive and promotive activity carved by ICDS (Integrated Child Development Services) to capture inadequate growth early enough and take the required action before the child suffers undernutrition. This study explores its functioning in Maharashtra. Data is collected in rural, urban and tribal settings from three districts. It includes observations during 93 GMP sessions and interviews of 100 AWWs, 78 supervisors and 500 mothers. The study reveals unavailability of proper child weighing scales and sometimes sophisticated instruments with inadequately trained staff. None of the workers plots the growth charts then and there and children are weighed in chaotic conditions during the session, resulting in incorrect weights. Most mothers have neither seen the growth charts nor do they understand it. Effective interaction with mothers is lacking which defeats the Programme. ICDS should try to improve this well-thought programme.

BUILDING EVALUATION PARTNERSHIPS WITH TRIBAL COMMUNITIES FOR HOME VISITING.

The goal of this current descriptive study was to examine the roles and relationships of evaluators with the tribal communities in which they work. First, we describe a participatory community research model with a strong capacity-building component as the standard for assessing successful working partnerships between evaluators, programs, tribes, and tribal organizations. This model serves as a yardstick against which we examine the success and challenges of program-evaluation partnerships. Second, we report on a survey of tribal Maternal, Infant, and Early Childhood Home Visiting program leaders and outline their impressions of successes and challenges related to program-evaluation partnerships. Survey participants discussed the importance of working with evaluators who have deep investment in and understanding of the tribal community; respect for cultural relevance and honor for cultural ways; collaboration that includes transparency, trust, and translation of research for community leaders and members; a focus on strength-based design without losing the need to consider challenges; and relationships of mutual trust that can weather addressing stressors when issues of conflict, limited resources, and/or mixed expectations arise.

Targeting risk factors for type 2 diabetes in American Indian youth: the Tribal Turning Point pilot study.

American Indian (AI) youth are at high risk for type 2 diabetes. To partner with Eastern Band of Cherokee Indians and Navajo Nation to develop a culturally sensitive behavioural intervention for youth (Tribal Turning Point; TTP) and assess feasibility in an 8-month randomized pilot study. We enrolled 62 overweight/obese AI children (7-10years) who participated with ≥1 parent/primary caregiver. Intervention participants (n=29) attended 12 group classes and five individual sessions. Control participants (n=33) attended three health and safety group sessions. We analysed group differences for changes in anthropometrics (BMI, BMI z-score, waist circumference), cardiometabolic (insulin, glucose, blood pressure) and behavioural (physical activity and dietary self-efficacy) outcomes. Study retention was 97%, and intervention group attendance averaged 84%. We observed significant treatment effects (p=0.02) for BMI and BMI z-score: BMI increased in control (+1.0kgm-2 , p<0.001) but not intervention participants (+0.3kgm-2 , p=0.13); BMI z-score decreased in intervention (-0.17, p=0.004) but not control participants (0.01, p=0.82). There were no treatment effects for cardiometabolic or behavioural outcomes. We demonstrated that a behavioural intervention is feasible to deliver and improved obesity measures in AI youth. Future work should evaluate TTP for effectiveness, sustainability and long-term impact in expanded tribal settings.

Evaluating the Cultural Fit of an Approach for Practice Model Development for Tribal Child Welfare

Three American Indian tribes utilized Business Process Mapping (BPM) as a tool to develop culturally-based tribal child welfare practice models. This study employed a multi-methods design to evaluate the cultural fit of BPM when used in tribal settings. Findings indicated that although programs considered BPM a “mainstream” intervention, each still found the process to be an effective means of creating models reflecting child welfare practice within tribal cultural contexts. Findings further suggested that BPM can, however, benefit from examination of how it might better articulate cultural values and norms, as well as differences between tribal and mainstream child welfare approaches.