Understanding American Indian tribal college student knowledge, attitudes, beliefs, and behaviors surrounding alternative tobacco products.

OBJECTIVES: To examine knowledge, attitudes, beliefs, and behaviors about alternative tobacco products among American Indian tribal college students. PARTICIPANTS: One hundred and five tribal college students. METHODS: Focus groups, one interview, and demographic surveys. RESULTS: Tobacco use varied across the sample with 35.2% of the participants being users of ENDS products and 29.5% were cigarette smokers. Overall, participants viewed electronic nicotine delivery systems and chewing tobacco as primary examples of alternative tobacco products and described a generational divide between alternative and conventional tobacco product use. Alternative tobacco products were not considered suitable for use in traditional contexts. CONCLUSIONS: Previously successful cessation programs in this population have relied on cultural tailoring related to traditional tobacco use in American Indian communities. Our findings suggest that this strategy may be less effective for addressing alternative tobacco use. Reliance on the importance of family relationships may prove more impactful in future programming.

Pilot Testing All Nations Snuff Out Smokeless (ANSOS): A Culturally Tailored Smokeless Tobacco Cessation Program for American Indians.

American Indians have the highest rates of smokeless tobacco (SLT) use of any racial/ethnic group in the United States, yet no proven effective cessation programs exist for them. Because tobacco is a sacred plant to many American Indians, cessation programs must not portray it in a completely negative manner. Based on our successful All Nations Breath of Life smoking cessation program, we developed and pilot-tested the All Nations Snuff Out Smokeless (ANSOS) program. Of 48 participants who began the program, 33 completed to six months (68.8% retention rate). Among participants who completed the program, 11 (34%) self-reported abstinence. When those lost to follow-up are considered current users, the cessation rate is 22.9%. An additional 14 individuals reported decreasing use (29.2% of all participants), with an average of 3.4 days per week decrease. All Nations Snuff Out Smokeless shows promise as a culturally appropriate SLT cessation program and is ready for efficacy testing.

Baseline characteristics of American Indian smokeless tobacco users participating in two pilot cessation studies.

American Indians have higher rates of smokeless tobacco (SLT) use than other racial/ethnic groups in the US, yet no efficacious cessation program exists for them. Because tobacco is a sacred plant to many American Indians, it is imperative that a program respect the scared nature of tobacco while encouraging quitting recreational use. All Nations Snuff Out Smokeless (ANSOS) was designed to help American Indian SLT users quit recreational tobacco use while still using it for traditional purposes. We pilot tested the ANSOS 6-month group-based counseling program (N = 48) and a shortened version consisting of a one-time education session (N = 80). Here, we discuss the tobacco characteristics of participants at baseline in both studies. Participants across studies were more likely to be male (74.2%) and have at least a college education (65%). Participants in the one-time education sessions were younger (age 35 vs age 39) and used SLT fewer days per week (4.9 vs 5.7). Two-thirds of those in the full program reported that they often substitute SLT in locations where smoking is not allowed compared to 26%. Participants in the education sessions were more likely to report daily use of traditional tobacco (20% versus 0%). Results suggest that dual use of SLT and cigarettes needs to be addressed, as does the use of SLT to circumvent public smoking rules. The role of traditional tobacco and its relationship to lower SLT use also warrants further investigation.

One-Time Education Sessions to Help American Indian Smokeless Tobacco Users Quit.

American Indian (AI) smokeless tobacco use rates are the highest of all racial/ethnic groups within the United States. Despite this, no effective cessation program currently exists that acknowledges the cultural significance of tobacco among many American Indian tribal nations. Participants were smokeless tobacco users, over 18 years of age, and were recruited through community partners. We modified the All Nations Snuff Out Smokeless Tobacco group-based program to be delivered as a one-time education session intervention. This was delivered to 80 participants and follow-up data was collected by self-report at 6-months. The mean age of participants was 35 and most were male (70%). A majority (69%) grew up on a AI reservation; the mean age of first smokeless tobacco use was 16 years of age. Of program completers reached for 6-month post baseline, 46% reported 0 days of SLT use; 13.5% of participants reduced; while 36% reported continued daily use. In intention to treat analysis those lost to follow-up are considered current users, the quit rate was 12.5% and among those who were still using, 4.0% reduced their use. In this study, a one-time education session intervention was effective for those who prefer an individual based approach to quitting SLT use. Follow up strategies to increase participant retention at 6-months should be explored.

Feasibility of Implementing the All Nations Breath of Life Culturally Tailored Smoking Cessation Program for American Indians in Multi-Tribal Urban Communities.

Introduction: Prevalence of cigarette smoking is highest among American Indians, yet few culturally appropriate smoking cessation programs have yet been developed and tested for multi-tribal American Indian adult populations. This study examined implementation of the All Nations Breath of Life culturally tailored smoking cessation program in multi-tribal urban and suburban American Indian communities in seven locations across five states (N = 312). Methods: This single-arm study used community-based participatory research to conduct a 12-week intervention whose primary purpose was to curb commercial tobacco use among American Indians. Participants were followed through month 6 in person and month 12 via telephone. The primary outcome was continuous abstinence from recreational cigarette smoking at 6 months post-baseline, verified through voluntary provision of salivary cotinine levels. Results: At program completion (12 weeks post-baseline), 53.3% of program completers remained abstinent; labeling those lost to follow-up as smokers resulted in a 41.4% quit rate. At 6 months post-baseline (primary endpoint), 31.1% of retained participants quit smoking (p < .0001 compared to the highest quit rates among multi-tribal populations reported in the literature, 7%); final quit rate was 22.1% labeling those lost to follow-up as smokers (p = .002). Retention rate at endpoint was 71.2%. 12-month follow-up was attempted with all participants and had a retention rate of 49.0%. Of those participants reached, 34.0% were smoke-free. Conclusions: All Nations Breath of Life shows promise as a smoking cessation program for multi-tribal urban American Indian communities. It can be successfully implemented in a variety of urban settings. Implications: This is the first large feasibility study of a culturally tailored smoking cessation program for American Indians with good cessation and retention rates in a multi-tribal urban American Indian population. It shows that All Nations Breath of Life can be implemented in multiple urban settings across five states. To our knowledge, this is the first program of its kind to be implemented across multiple heterogeneous urban locations and to include salivary cotinine testing for verification of self-report data across these locations.

American Indian Knowledge, Attitudes, and Beliefs About Smokeless Tobacco: A Comparison of Two Focus Group Studies.

Though smokeless tobacco (SLT) use has decreased in many communities, concern for American Indian (AI) SLT use remains, as this population continues to be disproportionally affected by SLT-related diseases. Tobacco has cultural significance to many AI tribes, therefore tobacco cessation messages portraying tobacco as entirely negative may be ineffective. As a part of our formative research for an SLT cessation intervention, we sought to gain a better understanding of the knowledge, attitudes, and beliefs about SLT among AI community members. We describe two independent focus group studies conducted in Montana (ten focus groups, 54 participants) and Kansas (six focus groups, 27 participants). Predominant themes emerged from three major topic areas (SLT use, program development, and recreational SLT use) during the discussions from both studies. The formative approach and data from these studies will allow us to more appropriately address SLT-related health disparities across multiple AI communities.

Recruitment and Baseline Characteristics of American Indian Tribal College Students Participating in a Tribal College Tobacco and Behavioral Survey.

INTRODUCTION: American Indians (AIs) have the highest cigarette smoking rates of any racial/ethnic group in the United States. Although the overall smoking prevalence in the United States for nonminority populations has decreased over the past several decades, the same pattern is not observed among AIs. The purpose of this observational study was to collect cigarette smoking and related information from American Indian tribal college students to inform tailored interventions. METHODS: We conducted a repeated cross-sectional survey of American Indian tribal college students, Tribal College Tobacco and Behavior Survey (TCTABS), with a focus on recruiting all incoming freshman at three participating tribal colleges in the Midwest and Northern Plains regions. A total of 1256 students participated in the baseline surveys between April 2011 and October 2014. RESULTS: The overall smoking prevalence of this sample was 34.7%, with differences by region (Northern Plains-44.0% and Midwest-28%). The majority, 87.5% of current smokers reported smoking 10 or less cigarettes per day, 41% reported smoking menthol cigarettes, 52% smoked Marlboro brand, and the mean age of their first cigarette was 14 years. The majority, 62% had made at least one quit attempt in the past year. The overwhelming majority of respondents, regardless of their smoking status, thought that the current smoking prevalence on campus was greater than 41% and approximately one-third believed that it was as high as 61%. CONCLUSIONS: Very few studies of smoking have been conducted in this population and results from our study confirm the need for effective interventions. IMPLICATIONS: AIs have the highest cigarette smoking rates compared to other racial/ethnic groups in the United States. Furthermore, limited studies have examined the epidemiology of cigarette smoking among tribal college students. This study addresses health disparities related to smoking among college students by examining the demographic, cultural, and environmental characteristics of smoking and quitting. Results from this study could lead to the development of a culturally-tailored smoking cessation and prevention program for American Indian tribal college students.

Geographic variation in colorectal cancer incidence and mortality, age of onset, and stage at diagnosis among American Indian and Alaska Native people, 1990-2009.

OBJECTIVES: We characterized estimates of colorectal cancer (CRC) in American Indians/Alaska Natives (AI/ANs) compared with Whites using a linkage methodology to improve AI/AN classification in incidence and mortality data. METHODS: We linked incidence and mortality data to Indian Health Service enrollment records. Our analyses were restricted to Contract Health Services Delivery Area counties. We analyzed death and incidence rates of CRC for AI/AN persons and Whites by 6 regions from 1999 to 2009. Trends were described using linear modeling. RESULTS: The AI/AN colorectal cancer incidence was 21% higher and mortality 39% higher than in Whites. Although incidence and mortality significantly declined among Whites, AI/AN incidence did not change significantly, and mortality declined only in the Northern Plains. AI/AN persons had a higher incidence of CRC than Whites in all ages and were more often diagnosed with late stage CRC than Whites. CONCLUSIONS: Compared with Whites, AI/AN individuals in many regions had a higher burden of CRC and stable or increasing CRC mortality. An understanding of the factors driving these regional disparities could offer critical insights for prevention and control programs.

Teaching Confirmatory Factor Analysis to Non-Statisticians: A Case Study for Estimating Composite Reliability of Psychometric Instruments.

Texts and software that we are currently using for teaching multivariate analysis to non-statisticians lack in the delivery of confirmatory factor analysis (CFA). The purpose of this paper is to provide educators with a complement to these resources that includes CFA and its computation. We focus on how to use CFA to estimate a "composite reliability" of a psychometric instrument. This paper provides guidance for introducing, via a case-study, the non-statistician to CFA. As a complement to our instruction about the more traditional SPSS, we successfully piloted the software R for estimating CFA on nine non-statisticians. This approach can be used with healthcare graduate students taking a multivariate course, as well as modified for community stakeholders of our Center for American Indian Community Health (e.g. community advisory boards, summer interns, & research team members). The placement of CFA at the end of the class is strategic and gives us an opportunity to do some innovative teaching: (1) build ideas for understanding the case study using previous course work (such as ANOVA); (2) incorporate multi-dimensional scaling (that students already learned) into the selection of a factor structure (new concept); (3) use interactive data from the students (active learning); (4) review matrix algebra and its importance to psychometric evaluation; (5) show students how to do the calculation on their own; and (6) give students access to an actual recent research project.

Characteristics of American Indian light smokers.

INTRODUCTION: American Indians (AI) have the highest smoking rates of any racial/ethnic group in the U.S. and have more difficulty quitting smoking. Little is known about the smoking characteristics of AI smokers. The present study compared the demographic and smoking characteristics of light (≤10 cigarettes per day; N=206) and moderate/heavy (11+ cigarettes per day; N=86) AI smokers participating in a cross-sectional survey about smoking and health. METHODS: Multiple methods were used to recruit participants in attendance at powwows, health and career fairs, and conferences. A total of 998 AI (76% cooperation rate) completed a survey assessing general health, sociodemographics, traditional and commercial tobacco use, knowledge and attitudes related to cancer, source of health information and care and other health-related behaviors. RESULTS: AI light smokers were younger and less likely to be married or living with a partner compared to moderate/heavy smokers. AI light smokers were less dependent on smoking and more likely to have home smoking restrictions. There were no differences with respect to number of quit attempts in the past year or the average length of their most recent quit attempt by light vs. moderate/heavy smoking. In addition, a similar proportion of light and heavy smokers reported using tobacco for traditional purposes such as ceremonial, spiritual and prayer. CONCLUSIONS: These findings highlight important differences between AI light and heavier smokers. Differences related to smoking characteristics such as level of dependence and home smoking restrictions have important implications for the treatment of AI smokers.

Assessment of mammography experiences and satisfaction among American Indian/Alaska Native women.

BACKGROUND: American Indian/Alaska Native (AI/AN) women have lower breast cancer (BCA) screening and 5-year survival rates than non-Hispanic Whites. Understanding reasons for low screening rates is important to combatting later stage diagnoses. The purpose of this study was to assess mammography experiences and satisfaction among AI/AN women. METHODS: Nine focus groups were held with rural (N = 15) and urban (N = 38) AI/AN women 40 years and older in Kansas and Kansas City, Missouri, living both near and far from Indian Health Service (IHS) and tribal facilities, to examine experiences and satisfaction with mammography. Transcripts were coded and themes identified using a community-based participatory research approach. FINDINGS: Themes were classified under knowledge, communication, and awareness of BCA; barriers to mammography; mammogram facility size; impressions of mammogram technologist; motivations for getting a mammogram; and how to improve the mammogram experience. Participants had knowledge of prevention, but described cultural reasons for not discussing it and described better experiences in smaller facilities. Participants indicated having a mammogram technologist who was friendly, knowledgeable, respectful, competent, and explained the test was a determining factor in satisfaction. Other factors included family history, physician recommendation, and financial incentives. Barriers included transportation, cost, perceptions of prejudice, and time constraints. Participants on reservations or near IHS facilities preferred IHS over mainstream providers. Suggestions for improvement included caring technologists, better machines with less discomfort, and education. CONCLUSIONS: Interventions to enhance the professionalism, empathy, and cultural awareness of mammogram technologists; reduce barriers; and provide positive expectations and incentives could improve satisfaction and compliance with screening mammography.

American Indian Community Leader and Provider Views of Needs and Barriers to Colorectal Cancer Screening.

Colorectal cancer is a great concern for the American Indian/Alaska Native (AI/AN) community, as incidence and mortality rates remain high and screening rates stay low. We conducted interviews with community leaders (n=13) and with providers from the Indian Health Service (IHS), tribal clinics, and urban safety-net clinics (n=17) in Northeast Kansas and the Kansas City Metro Area to determine their understanding of needs and barriers to colorectal cancer screening among American Indians. Using a community-based participatory research (CBPR) approach for this pilot study, community leaders and providers identified similar needs, including: culturally-appropriate education about colorectal cancer and screenings, the potential use of Native elders as patient navigators, and an emphasis on preventive care, particularly through the IHS. Barriers included culturally specific issues such as historic mistrust and gender roles. Other barriers are similar to members of other ethnic groups, such as cost, transportation, fear, and repulsion toward the screening process.

Use of online health information resources by American Indians and Alaska Natives.

According to the Office of Minority Health, an estimated 4.9 million people living in the United States consider themselves American Indian or Alaska Native, either alone or in combination with one or more races/ethnicities. American Indians or Alaska Natives comprise a racial/ethnic group experiencing serious health disparities, with little if any improvement in health outcomes over the past several decades. This study was designed to explore use of the Internet as a health information source among American Indians in the Central Plains region of the United States. The authors recruited 998 Natives in the region from May 2008 to December 2009 at powwows, health fairs, focus groups, career fairs and conferences, and other social and cultural events, and asked them to complete a self-administered survey. Although compared with data from the general population, American Indians or Alaska Natives in this sample may seem to be more frequent Internet users, their use of modern wireless devices is limited, and their use of the Internet to access health information is lower in comparison with the adult U.S. population. Natives living in the Central Plains region face generational differences in general and health-related use of the Internet. Inadequate availability of culturally appropriate health information websites may drive American Indians or Alaska Natives toward search engines and general information websites.

Improving health promotion to American Indians in the midwest United States: preferred sources of health information and its use for the medical encounter.

American Indians and Alaska Natives suffer significant health disparities for many infectious and chronic diseases as compared to the general population. Providing accurate and culturally tailored health information to underserved groups has been shown to influence health behaviors and health outcomes. Little prior research has explored American Indians health information use and preferences. National representative sample surveys such as the Health Information National Trends Survey provide some data on minority groups but are underpowered to provide useful information on American Indians. The present study analyzes data from a survey of over 900 American Indians from the Midwest United States and explores their sources of health information, their preferences for information presentation, and their use of health information prior to and during medical encounters. We conclude that campaigns targeting Natives should be narrowly focused and be community driven or employing community resources. American Indians use a diversity of media sources to obtain health information, with the Internet being underutilized compared to the general population. Partnership with Indian Health Service providers and pharmacists, as well as traditional healers, in the development and dissemination of new health information for Natives may provide the "expert" tone needed to promote health improvements in American Indians.

Breast cancer screening beliefs and behaviors among American Indian women in Kansas and Missouri: a qualitative inquiry.

American Indian women have rising incidence and disproportionate mortality rates due to breast cancer. Using a community-based participatory research approach, we conducted ten focus groups with American Indian women in Kansas and Missouri to understand their barriers to mammography and identify ways to intervene to improve screening rates. Focus groups were stratified by screening status, including women who were up to date with current screening mammography recommendations (mammogram within the last 2 years, N = 7 groups, 66 participants) and women who were not (N = 3 groups, 18 participants). While many similarities were identified across strata, some differences emerged, particularly descriptions of prior negative experiences with the health care system among women who were not up to date with screening recommendations. Primary areas identified by participants for intervention included culturally appropriate educational materials and interventions directed specifically at improving American Indian women's trust in Western medicine and alleviating feelings of discrimination.

A computerized intervention to promote colorectal cancer screening for underserved populations: theoretical background and algorithm development.

OBJECTIVE: The aim of this exploratory study was to assess factors deemed by patients as "important" as they planned and considered undergoing colorectal cancer (CRC) screening, and to use this data to design a computer-delivered intervention to promote screening. METHODS: Fifty participants 50 years or older, not up-to-date with current recommended CRC screening guidelines, were recruited from a primary care clinic. A semi-structured interview focused on aspects of preparing for colorectal cancer screening was administered; after transcription, researchers used triangulation and consensus to identify relevant themes and concepts. RESULTS: Four main themes were identified that dealt with issues important for both FOBT and colonoscopy planning: personal concerns, reminders, communication with healthcare providers and obtaining test results. FOBT specific themes included: sample collection and return. For colonoscopy screening, themes included: scheduling, intervention questions, colonoscopy preparation, and transportation. These can be classified as barrier, process and accessory themes. The developed computer-administered implementation intentions algorithm addressed all the identified concerns in a planned and sequential manner, in order to facilitate planning for CRC screening. CONCLUSIONS: The results of this study suggest that appropriate reminders, explanations of procedures, and patient understanding of temporary life disruptions, help patients develop and accept a detailed screening plan.

Physical activity and fruit and vegetable intake among American Indians.

The American Indian population has among the highest rates of obesity in the United States. Thus, it is critical to understand factors related to this epidemic (e.g., physical activity, nutrition) among this ethnic minority population. The current study examined factors related to engaging in at least 4 days of physical activity (PA) per week and factors related to consuming at least 5 fruits and vegetables (FV) per day among a sample of American Indians in the Midwest. We used multiple methods to recruit participants for this study, including recruitment at pow wows, focus groups, health fairs, new student orientation for American Indian students, and other venues. A total of 998 American Indians (76% participation rate) completed a survey assessing sociodemographics, physical activity level, fruit and vegetable intake, and perceptions regarding the recommendations for physical activity and fruit and vegetable intake. Factors associated with exercising ≥4 days in the past week (44.77% of the sample) include being younger (P = .002), being male (P < .001), having at least some college education (P = .048), eating ≥5 FV per day, and higher perceived number of days of PA recommended (P < .001). Factors associated with eating ≥5 servings of FV per day (37.01% of the sample) included exercising ≥4 days in the past week (P < .001) and higher perceived number of servings of FV recommended (P < .001). These findings highlight the importance of education in enhancing engagement in positive weight control behaviors and the importance of addressing both physical activity and nutrition among the American Indian population.

Smoke-Free Policies in the Workplace and in the Home among American Indians.

OBJECTIVES: American Indians are more likely to smoke, less likely to have smoke-free homes, and potentially less likely to have worksite smoke-free policies. We examined correlates of smoke-free policies at home and work among a community-based sample of American Indians in the Midwest. METHODS: We examined correlates of smoke-free policies at home and work in a sample of American Indians in the Midwest using a community-based participatory research approach. RESULTS: 66.7% were nonsmokers, 15.6% smoked on some days, and 17.6% smoked every day. The majority (72.4%) had complete smoke-free home policies, 13.1% had partial restrictions, and 14.5% had no rules. Moreover, 62.7% had complete smoke-free worksite policies, 27.9% had partial policies, and 9.4% had no worksite smoke-free policies. Factors associated with having a complete smoke-free home policy included being a college graduate (p=.005) and a nonsmoker versus a nondaily (p=.006) or a daily smoker (p<.001). Correlates of having a complete smoke-free worksite policy included being female (p=.005) and a nonsmoker versus a nondaily (p=.03) or a daily smoker (p<.001). Having complete worksite policies was associated with having smoke-free homes (p<.001). CONCLUSIONS: Having complete worksite policies was related to having smoke-free home policies; both were associated with being a nonsmoker.

Adapting pressure ulcer prevention for use in home health care.

PURPOSE: Clinical practice guidelines on pressure ulcer (PU)prevention have been written primarily for inpatient settings,but we currently lack data as to how these guidelines have been adapted for use in home health care. The purpose of this study was to delineate interventions and activities used to prevent PU in home health care. DESIGN: Focus group study using text analysis. SUBJECTS: A focus group was conducted with 9 certified wound care nurses who practiced in home health care at least 50% of the time. Most of the participants had 10 or more years of home health experience and 5 or more years of wound care experience. METHODS: The single 75-minute focus group was convened by teleconference and audiotaped. A semistructured moderator's guide was used to lead the discussion. Transcribed data were analyzed using standard text analysis. Preliminary results were distributed to focus group participants for review, comment, or clarification, and refined as needed. RESULTS: Certified wound care nurse participants used an array of interventions, including those recommended by clinical practice guidelines, to prevent PU in home health patients.However, specific activities differed from those performed in hospitals and nursing homes. Interventions unique to homehealth care included (1) assessment of patients' economic and insured status to determine implementation options, (2) assessment of caregiving resources and caregivers' ability to manage PU prevention, and (3) collaboration with community resources and health care vendors to obtain needed prevention materials and supplies. CONCLUSION: Findings provide insight into guideline adaptation in home health care and suggest that PU prevention in the homehealth care setting is more complex than that in hospitals and nursing homes and requires significant skills in communication and collaboration.

All Nations Breath of Life: using community-based participatory research to address health disparities in cigarette smoking among American Indians.

Using a community-based participatory research (CBPR) approach, we developed the All Nations Breath of Life smoking cessation program and pilot-tested it in urban and reservation communities. The program combines weekly in-person group support sessions with individual telephone calls using motivational interviewing. All sessions include discussion of sacred tobacco and information about quitting and health. We have assessed the scientific validity, cultural-appropriateness, and readability of our program materials and found them to be adequate; participant satisfaction is high. The program shows promise for improving quit rates among American Indians, who have the highest smoking rates and lowest quit rates of any ethnic group. Our preliminary self-report data show quit rates of 65% at program completion and 25% at six months post-baseline.