The epidemiologic evidence underlying recommendations for use of pneumococcal polysaccharide vaccine among American Indian and Alaska Native populations

Alaska Native and some American Indian (AI/AN) populations suffer disproportionately high rates of invasive pneumococcal disease (IPD) in both the pediatric and adult populations compared to the general U.S. population. Two pneumococcal vaccines are currently available in the U.S.: a 23-valent pneumococcal polysaccharide vaccine (PPSV23), available since 1983 and recommended for the elderly and those over 2 years of age with underlying medical conditions, and a 13-valent pneumococcal conjugate vaccine (PCV13), used in the routine infant immunization schedule since 2010. The U.S. Advisory Committee on Immunization Practice (ACIP) previously recommended use of PPSV23 for persons living in special environments or social settings, including AN and certain AI persons 2-64 years of age, on the basis of higher disease rates. The recommendation for routine PPSV23 use among AI/AN persons <65 years of age, regardless of underlying conditions, was removed in 2008, although the option for use among those 50-64 years of age living in areas with high pneumococcal disease rates was maintained. The rationale for the revised recommendations lay in the recognition that much of the excess disease burden occurs among those with an existing medical indication for PPSV23. Other considerations for the change were the potential risks of giving multiple PPSV23 doses and the considerable heterogeneity in pneumococcal disease risk among American Indian populations requiring a more tailored approach to local recommendations based on local epidemiology.     

Health and Ambulatory Care Use Among Native American Veterans

In 1995, the Veterans Health Administration reorganized its health services structure to emphasize ambulatory care. Successful health care planning and improving access to ambulatory care services now depends upon a better understanding of health care needs and outpatient services. Because the veteran population is heterogeneous, it is important to understand the health, access issues, and utilization of ambulatory care services in order to develop effective strategies and interventions to ensure access to and utilization of ambulatory care. Drawing on a focus group methodology with 86 Native American veterans, representing 34 tribes, this study is a qualitative examination of the health, access, use of the Department of Veterans Affairs Health Care services, barriers to health care, and satisfaction with care experienced by Native American veterans. Results reveal problems in accessing care, receiving appropriate care, and coordinating care within the VA health care system. Policy and program recommendations include increasing outreach and education efforts regarding the availability of benefits and services, improving coordination of services between the Indian Health Service and the VA, and reemphasizing the importance of patient-centered care.     

Alcohol/drug exposure, HIV-related sexual risk among urban American Indian and Alaska Native Youth: evidence from a national survey

BACKGROUND: Migration of the native populations from reservations to the urban areas has resulted in mixed ethnicities of American Indian/Alaskan Native (AIAN) children. Minority youth require special attention and services in urban schools as they disproportionately experience poverty, low educational attainment, unemployment, and single‐parent status. METHODS: We used 2005 and 2007 Youth Risk Behavior Survey data to examine alcohol/drug use patterns and their association with sexual risk taking among AIAN only (single‐racial) and biracial youth in combination with White, African American, or Hispanic ethnicities (N = 1178). RESULTS: Overall, one half of the students were sexually active, with significantly higher rates among males; AIAN‐Black students initiated sex earlier than the other groups. Condom nonuse is higher among AIAN‐Whites (>50%) compared to one third of AIAN‐Hispanics and one fourth of AIAN‐Blacks. Nearly 10% of all students, except AIAN‐Blacks, reported lifetime use of heroin/meth. Sexual behavior was significantly associated with episodic drinking. Students with Hispanic background have twice the odds of being sexually active compared to AIANs. CONCLUSIONS: Our findings underscore growing health care needs and targeted prevention initiatives for mixed racial underserved native youth. Urban school settings have potential to deliver services and offer alcohol/drug prevention programs to address the needs of mixed racial native urban youth. Using the School Based Health Clinic model has been successful; we need to reform prevention approaches to accommodate needs of multiracial urban native youth.     

Barriers to Cancer Clinical Trial Participation Among American Indian and Alaska Native Tribal College Students

Purpose: American Indians and Alaska Natives (AIs/ANs) have some of the highest cancer‐related mortality rates of all US racial and ethnic groups, but they are underrepresented in clinical trials. We sought to identify factors that influence willingness to participate in cancer clinical trials among AI/AN tribal college students, and to compare attitudes toward clinical trial participation among these students with attitudes among older AI/AN adults. Methods: Questionnaire data from 489 AI/AN tribal college students were collected and analyzed along with previously collected data from 112 older AI/AN adults. We examined 10 factors that influenced participation in the tribal college sample, and using chi‐square analysis and these 10 factors, we compared attitudes toward research participation among 3 groups defined by age: students younger than 40, students 40 and older, and nonstudent adults 40 and older. Findings: About 80% of students were willing to participate if the study would lead to new treatments or help others with cancer in their community, the study doctor had experience treating AI/AN patients, and they received payment. Older nonstudent adults were less likely to participate on the basis of the doctor's expertise than were students (73% vs 84%, P = .007), or if the study was conducted 50 miles away (24% vs 41%, P= .001). Conclusions: Finding high rates of willingness to participate is an important first step in increasing participation of AIs/ANs in clinical trials. More information is needed on whether these attitudes influence actual behavior when opportunities to participate become available.     

Breast cancer survival of American Indian/Alaska Native women, 1973-1996

Summary. Objective: To assess breast cancer mortality rates among American Indian/Alaska Native women compared with non-Hispanic White women in the five years after diagnosis.Methods: Surveillance, Epidemiology, and End Results data from 1973–1996 were used to compare survival in the two races, controlling for age, marital status, stage, and therapy.Results: The adjusted relative hazard of death was 58% higher for American Indian/Alaska Native women than for non-Hispanic White women (HR = 1.58, 95% CI 1.26–2.00). The survival disparity persisted even when limited to women who received definitive therapy, i.e. mastectomy with axillary node dissection or breast-conserving surgery with axillary node dissection and radiation treatment (HR = 1.88, 95% CI 1.40–2.52).Conclusions: American Indian/Alaska Native women were at greater risk for breast cancer mortality than non-Hispanic White women, even when restricted to women who received definitive breast cancer therapy.

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Zusammenfassung. Überlebensraten nach Brustkrebs bei amerikanischen Frauen indianischen Ursprungs und aus Alaska, 1973–1996Fragestellung: Vergleichen der Brustkrebsmortalitätsraten von amerikanischen Frauen indianischen Ursprungs und aus Alaska mit weissen, nicht-lateinamerikanischen Frauen fünf Jahre nach der Diagnose.Methode: Die Surveillance-, epidemiologischen und die Endergebnisse der zwischen 1973 und 1996 erhobenen Daten wurden gebraucht, um das Überleben zwischen den zwei ethni schen Gruppen zu vergleichen, die Daten wurden für Alter, Zivilstand, Entwicklungsstand und Therapie des Krebses kontrolliertErgebnisse: Das angepasste relative Risiko war 58% höher für amerikanischen Frauen indianischen Ursprungs und aus Alaska als für weisse, nicht-lateinamerikanische Frauen (OR = 1,58; 95%-KI 1,26–2,00). Dieser Unterschied bleibt auch dann noch bestehen, wenn nur noch für Frauen mit chirurgischer Therapie, d.h. Brustamputation und Entnahme der Lymphknoten der Achselhöhle oder brusterhaltende Operation mit Entnahme der Lymphknoten der Achselhöhle und Strahlentherapie, gerechnet wurde (OR =1,95%-KI 1,40–2,52).Schlussfolgerung: Amerikanische Frauen indianischen Ursprungs und aus Alaska haben ein grösseres Risiko für Brustkrebsmortalität als weisse, nicht-lateinamerikanische Frauen, sogar wenn der Vergleich nur für Frauen mit einer chirurgischen Therapie gemacht wurde.

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Résumé. Survie post cancer du sein chez les femmes américaines d’origine indienne ou d’Alaska, 1973–1996Objectifs: Comparer les taux de mortalité par cancer du sein cinq ans après le diagnostic chez les femmes américaines d’origine indienne ou d’Alaska et chez les femmes blanches non-hispaniques.Méthodes: Les résultats (surveillance, épidémiologie et issues) enregistrés entre 1973 et 1996 ont été utilisés pour comparer la survie entre les deux groupes ethniques ; ils ont été contrôlés pour l’âge, l’état civil, le stade de développement du cancer et le traitement.Résultats: Le risque relatif ajusté était de 58% supérieur pour les femmes américaines d’origine indienne ou d’Alaska comparé aux femmes blanches non-hispaniques (OR = 1.58, 95% CI 1.26–2.00). La différence de survie restait présente lorsque la comparaison se limitait aux femmes ayant subi des traitements, c’est-à-dire soit une mastectomie avec ablation des nodules axillaires, soit une chirurgie conservatrice du sein avec radiothérapie (OR =1.88, 95% CI 1.40–2.52).Conclusions: Les femmes américaines d’origine indienne ou d’Alaska avaient un plus grand risque de mourir d’un cancer du sein que les femmes blanches non-hispaniques, même lorsque la comparaison était limitée aux femmes ayant bénéficié d’un traitement définitif du cancer de sein.

     

医学生与非医学生性及生殖健康认知调查

目的 了解和比较在校医学生与非医学生婚前性行为态度、生殖健康知识和生殖健康来源可信度等情况,以便有针对性地开展生殖健康教育。方法 采用便利抽样方法,对广东省广州市2所医学院校和2所非医学院校的763名在校大学生进行匿名问卷调查。结果 56.5%的大学生对婚前性行为持赞同态度,>60.0%的大学生反对婚前怀孕、婚前流产,94.1%的大学生认为未婚怀孕可以引起心理损伤;大学生对生殖健康内容和性传播疾病名称回答率偏低,医学生对生殖健康内容、性传播疾病名称的完全正确回答率均明显高于非医学生(P均<0.01);大学生认为生殖健康信息来源最可靠的前3位依次是医务人员、健康教育人员、教学课程。结论 应根据大学生生殖健康认知情况,在大学健康教育课程中开展生殖健康教育。     

Pap Smear Screening among Urban Southwestern American Indian Women

Background. American Indian women have among the highest incidence and mortality rates of cervix cancer in the United States. The incidence of cancer of the cervix among American Indians is 19.5/100,000 versus 7.8/100,000 in U.S. whites, and comparison by geographic region/tribe indicates that the rate is four to six times higher in some tribes. Papanicolaou cytological testing (Pap smear) permits the detection of cervical lesions before they become cancerous, effectively reducing the incidence of cervical cancer by 75–90%. The American Cancer Society recommends a Pap smear every year beginning at age 18 years or when sexually active, and more frequent screening in high-risk populations.Methods. A random household cross-sectional survey was conducted in Phoenix, Arizona, to assess cervical cancer screening rates among 519 adult urban American Indian women. Logistic regression was used to identify predictors of Pap smear use.Results. Three-quarters (76.1%) of urban women American Indian surveyed received a Pap smear within the past 3 years, but only 49.5% received a Pap smear within the last year. Women over age 50 years were significantly less likely to have received a recent Pap smear in comparison to younger women.Conclusions. The results of this study indicate that limited access to health care and lack of knowledge about the procedure were important barriers to Pap smear use. Improving cervix cancer screening participation rates is an important step in reducing the disease burden in this high-risk population.     

Self-reported asthma among American Indian and Alaska Native people in Alaska

This study describes the lifetime prevalence of self-reported asthma among American Indian and Alaska Native (AI/AN) people who participated in the Education and Research Towards Health (EARTH) study in Alaska. We conducted a cross-sectional analysis of asthma prevalence by sex and its associations with sociodemographic, health, and environmental factors. Among 3,828 AI/AN adults, we found a higher age-sex adjusted prevalence of asthma (15.4%) than is found in the general U.S. adult (11.0%) population based on the 2006 National Health Interview Survey. After multivariable analysis, self-reported asthma among men was associated with increased age, unemployment, lower income, and obesity. Among women, self-reported asthma was associated with increased age, being divorced/separated, living in Alaska's southcentral region, self-reported fair/poor health status, obesity, and indoor mold. Our data suggest that AI/AN adults have higher prevalence of lifetime asthma than the general U.S. population. Further study is necessary to understand asthma in this population.     

Misalignment of sexual and reproductive health priorities among older Latino adolescents and their mothers

Objective

The study describes maternal and adolescent perspectives on sexual decision making and the role of mothers in shaping use of contraception for the prevention of unplanned pregnancies and sexually transmitted infections (STIs) among older Latino adolescents.

Motor vehicle deaths among American Indian and Alaska Native populations

In the United States, the American Indian and Alaska Native (AI/AN) population has the highest motor vehicle death rate, which is significantly greater than that of any other race or ethnic group. To better understand why this significant disparity exists and how to eliminate it, the authors conducted a systematic review of the published scientific literature. Included studies were published between January 1, 1990, and January 31, 2011, and identified risk factors, or implemented and tested interventions, targeting motor vehicle deaths among the AI/AN population. Only 14 papers met the study's inclusion criteria. Most of the epidemiologic studies explored alcohol use as a risk factor for deaths of both motor vehicle occupants and pedestrians; few studies addressed risk factors specifically for pedestrians. All of the intervention studies focused on mitigating risks for motor vehicle occupants. On the basis of the authors' review, injury prevention interventions that are multifaceted and involve partnerships to change policy, the environment, and individual behavior can effectively mitigate motor-vehicle-related deaths among AI/ANs. Priority should be given to implementing interventions that address pedestrian safety and to sound investment in the states with the highest AI/AN motor vehicle death rates because reducing their burden can dramatically reduce the overall disparity.     

Asthma prevalence among American Indian and Alaska Native children.

OBJECTIVES: Although asthma is the most common chronic childhood illness in the United States, little is known about its prevalence among American Indian and Alaska Native (AI/AN) children. The authors used the latest available household survey data to estimate the prevalence of asthma in this population. METHODS: The authors analyzed data for children ages 1 through 17 years from the 1987 Survey of American Indians and Alaska Natives (SAIAN) and the 1987 National Medical Expenditure Survey (NMES). At least one member of each AI/AN household included in the SAIAN was eligible for services through the Indian Health Service. RESULTS: The weighted prevalence of parent-reported asthma was 7.06% among 2288 AI/AN children ages 1-17 (95% CI 5.08, 9.04), compared with a US estimate of 8.40% for children ages 1-17 based on the 1987 NMES (95% CI 7.65, 9.15). The AI/AN sample was too small to yield stable estimates for a comparison between AI/AN children and all US children when the data were stratified according to household income and metropolitan vs non-metropolitan residence. The unadjusted asthma prevalence rates were similar for AI/AN children and for children in the NMES sample. CONCLUSIONS: In 1987, the prevalence of parent-reported asthma was similar for AI/AN children in the SAIAN sample and for children in the NMES sample. More recent data are needed to better understand the current prevalence of asthma among AI/AN children.     

Correlates of Human Papillomavirus Vaccination Among Female University Students

Human papillomavirus (HPV) is the most frequently occurring sexually transmitted infection in the United States, but only one third of adolescent girls have received the HPV vaccine (Centers for Disease Control and Prevention [CDC], 2012; Committee on Infectious Diseases, 2012). Understanding correlates of vaccination behavior among young women has important implications for health care delivery and public service messages targeting HPV vaccination. Female college students (N = 313) completed web-based surveys during their sophomore (second) year of college, fall 2008. Surveys included questions about HPV vaccination, demographic factors (ethnicity/race, socioeconomic status [SES]), individual characteristics (romantic relationship status, grade point average, religiosity), and sexual behavior. Lifetime HPV vaccination was reported by 46.5% of participants. Being African American/Black was associated with a lower likelihood of vaccination. Having a mother with more education, adhering to religious teachings about sex-related principles, and having engaged in recent penetrative sex were associated with a higher likelihood of vaccination. Health care providers should consider young women to be an important group for HPV vaccine education and catch-up, particularly for African American/Black young women and young women from lower SES backgrounds. Providing vaccine education and access to young women before they become sexually active is critical.     

A culturally tailored research ethics training curriculum for American Indian and Alaska Native communities: a randomized comparison trial

The primary aim of this study was to develop an American Indian and Alaska Native (AIAN) tailored research with human subjects curriculum that would increase the participation of AIAN members in research affecting their communities. We used a community-engaged research approach to co-design and evaluate a culturally tailored online human subjects curriculum among a national sample of AIAN community members (n = 244) with a standard nationally used online curriculum (n = 246). We evaluated pre- and post-test measures to assess group differences in ethics knowledge, perceived self-efficacy to apply such knowledge to protocol review, and trust in research. Analysis of regional tribal differences assessed curriculum generalizability. Using an 80% correct item cut-off at first attempt as passing criterion, the tailored curriculum achieved a 59.3% passing rate versus 28.1% in the standard curriculum (p < .001). For both arms, participants reported a significant increase in trust in research and in research review efficacy. Participants took less time to complete the training and reported significantly higher acceptability, satisfaction, and understandability of the curriculum for the tailored curriculum. This culturally tailored research ethics curriculum has the potential to increase participation in AIAN communities in research affecting tribal members. The AIAN curriculum achieved significantly higher levels of participants’ research ethics knowledge, self-efficacy in reviewing research protocols, trust in research, and completion of the training requirements. Culturally grounded training curricula may help remedy the impact of historical research ethics abuses involving AIAN communities that have contributed to mistrust of research and lack of community engagement in research.     

Infectious disease hospitalizations among older American Indian and Alaska Native adults

OBJECTIVES: American Indians and Alaska Natives (AI/AN) adults > or = 65 years of age (older adults) have the second highest age group-specific infectious disease (ID) hospitalization rate. To assess morbidity and disparities of IDs for older AI/AN adults, this study examined the epidemiology of overall and specific infectious disease hospitalizations among older AI/AN adults. METHODS: ID hospitalization data for older AI/AN adults were analyzed by using Indian Health Service hospital discharge data for 1990 through 2002 and comparing it with published findings for the general U.S. population of older adults. RESULTS: ID hospitalizations accounted for 23% of all hospitalizations among older AI/AN adults. The average annual ID hospitalization rate increased 5% for 1990-1992 to 2000-2002; however, the rate increased more than 20% in the Alaska and the Southwest regions. The rate for older AI/AN adults living in the Southwest region was greater than that for the older U.S. adult population. For 2000-2002, lower respiratory tract infections accounted for almost half of all ID hospitalizations followed by kidney, urinary tract, and bladder infections, and cellulitis. CONCLUSIONS: The ID hospitalization rate increased among older AI/AN adults living in the Southwest and Alaska regions, and the rate for the older AI/AN adults living in the Southwest region was higher than that for the U.S. general population. Prevention measures should focus on ways to reduce ID hospitalizations among older AI/AN adults, particularly those living in the Southwest and Alaska regions.     

The Health of American Indian and Alaska Native Women,Infants and Children

Maternal and Child Health Journal -