Eva Marie Garroutte

Spirituality and attempted suicide among American Indians

American Indians exhibit suicide-related behaviors at rates much higher than the general population. This study examines the relation of spirituality to the lifetime prevalence of attempted suicide in a probability sample of American Indians. Data were derived from a cross-sectional sample of 1456 American Indian tribal members (age range 15-57yr) who were living on or near their Northern Plains reservations between 1997 and 1999. Data were collected by personal interviews. Commitment to Christianity was assessed using a measure of beliefs. Commitment to tribal cultural spirituality (or forms of spirituality deriving from traditions that predate European contact) was assessed using separate measures for beliefs and spiritual orientations. Results indicated that neither commitment to Christianity nor to cultural spirituality, as measured by beliefs, was significantly associated with suicide attempts (p(trend) for Christianity=0.22 and p(trend) for cultural spirituality=0.85). Conversely, commitment to cultural spirituality, as measured by an index of spiritual orientations, was significantly associated with a reduction in attempted suicide (p(trend)=0.01). Those with a high level of cultural spiritual orientation had a reduced prevalence of suicide compared with those with low level of cultural spiritual orientation. (OR=0.5, 95% CI=0.3, 0.9). This result persisted after simultaneous adjustment for age, gender, education, heavy alcohol use, substance abuse and psychological distress. These results are consistent with anecdotal reports suggesting the effectiveness of American Indian suicide-prevention programs emphasizing orientations related to cultural spirituality.

Access, Relevance, and Control in the Research Process: Lessons From Indian Country

Objective:To illustrate successful strategies in working with American Indian (AI) and Alaska Native (AN) communities in aging and health research by emphasizing access, local relevance, and decision-making processes. Methods:Case examples of health studies involving older AIs (≥50 years) among Eastern Band Cherokee Indians, a federally recognized reservation; the Cherokee Nation, a rural, nonreservation, tribal jurisdictional service area; and Lakota tribal members living in Rapid City, South Dakota. Results: Local reviewand decision making reflect the unique legal and historical factors underpinning AI sovereignty. Although specific approval procedures vary, there are common expectations across these communities that can be anticipated in conceptualizing, designing, and implementing health research among native elders. Conclusions:Most investigators are unprepared to address the demands of health research in AI communities. Community-based participatory research in this setting conflicts with investigators’ desire for academic freedom and scientific independence. Successful collaboration promises to enhance research efficiencies and move findings more quickly to clinical practice.

Food Insecurity and Obesity Among American Indians and Alaska Natives and Whites in California

Food insecurity is linked to obesity among some, but not all, racial and ethnic populations. We examined the prevalence of food insecurity and the association between food insecurity and obesity among American Indians (AIs) and Alaska Natives (ANs) and a comparison group of whites. Using the 2009 California Health Interview Survey, we analyzed responses from 592 AIs/ANs and 7371 white adults with household incomes at or below 200% of the federal poverty level. Food insecurity was measured using a standard 6-item scale. Sociodemographics, exercise, and obesity were all obtained using self-reported survey data. Logistic regression was used to estimate associations. The prevalence of food insecurity was similar among AIs/ANs and whites (38.7% vs 39.3%). Food insecurity was not associated with obesity in either group in analyses adjusted for sociodemographics and exercise. The ability to afford high-quality foods is extremely limited for low-income Californians regardless of race. Health policy discussions must include increased attention on healthy food access among the poor, including AIs/ANs, for whom little data exist. [Supplemental materials are available for this article. Go to the publishers online edition of Journal of Hunger & Environmental Nutrition to view the free supplemental file: Supplemental Tables.doc.].

Affective Interactions in Medical Visits Ethnic Differences Among American Indian Older Adults

Objective: Investigate influence of ethnicity on older American Indian patients’ interpretations of providers’ affective behaviors. Method: Using data from 115 older American Indian patients, random effects ordered logit models related patient ratings of providers’ respect, empathy, and rapport first to separate measures of American Indian and White American ethnicity, then to “ethnic discordance,” or difference between providers’ and patients’ cultural characteristics. Results: In models accounting for patients’ ethnicity only, high scores for American Indian ethnicity were linked to reduced evaluations for providers’ respect; high scores on White ethnicity were associated with elevated ratings for empathy and rapport. In models accounting for provider–patient ethnic discordance, high discordance on either ethnicity scale was associated with reduced ratings for the same behaviors. Discussion: Findings support “orthogonal ethnic identity” theory and extend “cultural health capital” theory, suggesting a pathway by which ethnicity becomes relevant to experience of health care among older adults.

Transdisciplinary Cardiovascular and Cancer Health Disparities Training: Experiences of the Centers for Population Health and Health Disparities

The Centers for Population Health and Health Disparities program promotes multilevel and multifactorial health equity research and the building of research teams that are transdisciplinary. We summarized 5 areas of scientific training for empowering the next generation of health disparities investigators with research methods and skills that are needed to solve disparities and inequalities in cancer and cardiovascular disease. These areas include social epidemiology, multilevel modeling, health care systems or health care delivery, community-based participatory research, and implementation science. We reviewed the acquisition of the skill sets described in the training components; these skill sets will position trainees to become leaders capable of effecting significant change because they provide tools that can be used to address the complexities of issues that promote health disparities.

Medical Communication in Older American Indians: Variations by Ethnic Identity

The authors analyzed audiotapes from 102 patients of American Indian race (≥50 years) to explore how ethnic identity influences medical communication. A standardized interaction analysis system was used to classify patient utterances into categories: information-giving, questions, social talk, positive talk, negative talk. The authors identified patient subgroups distinguished by level of identification with American Indian and White identity and explored whether some subgroups devoted more communication to certain categories of talk. Patients highly affiliated with American Indian identity devoted a significantly greater percentage of communication to “positive talk”—including statements of optimism, reassurance, and agreement—than patients identifying at lower levels (p > .05). They devoted less communication to “negative talk,” including corrections, disagreements, and anxiety statements (p < .05). Effects persisted after adjustment for confounders, including health status. Patterns may encourage providers to underestimate distress and overestimate satisfaction and comprehension in patients highly affiliated with American Indian identity.

Low-level inorganic arsenic exposure and neuropsychological functioning in American Indian elders

Background: Inorganic arsenic at high and prolonged doses is highly neurotoxic. Few studies have evaluated whether long‐term, low‐level arsenic exposure is associated with neuropsychological functioning in adults. Objectives: To investigate the association between long‐term, low‐level inorganic arsenic exposure and neuropsychological functioning among American Indians aged 64–95. Methods: We assessed 928 participants in the Strong Heart Study by using data on arsenic species in urine samples collected at baseline (1989–1991) and results of standardized tests of global cognition, executive functioning, verbal learning and memory, fine motor functioning, and speed of mental processing administered during comprehensive follow‐up evaluations in 2009–2013. We calculated the difference in neuropsychological functioning for a 10% increase in urinary arsenic with adjustment for sex, age, education, and study site. Results: The sum of inorganic and methylated arsenic species (∑As) in urine was associated with limited fine motor functioning and processing speed. A 10% increase in ∑As was associated with a .10 (95% CI −.20, −.01) decrease on the Finger Tapping Test for the dominant hand and a .13 decrease (95% CI −.21, −.04) for the non‐dominant hand. Similarly, a 10% increase in ∑As was associated with a .15 (95% CI −.29, .00) decrease on the Wechsler Adult Intelligence Scale–Fourth Edition Coding Subtest. ∑As was not associated with other neuropsychological functions. Conclusions: Findings indicate an adverse association between increased urinary arsenic fine motor functioning and processing speed, but not with other neuropsychological functioning, among elderly American Indians. HighlightsWe study arsenics effect on neuropsychological health of older American Indians.We assess arsenic from 1991 and neuropsychological test results 20 years later.We find that arsenic exposure lowers fine motor functioning and processing speed.

A Comparison of Colorectal Cancer Screening Uptake Among Average-Risk Insured American Indian/Alaska Native and White Women

Introduction. American Indian and Alaska Native (AI/AN) women have among the lowest rates of colorectal cancer (CRC) screening. Whether screening disparities persist with equal access to health care is unknown. Methods. Using administrative data from 1996–2007, we compared CRC screening events for 286 AI/AN and 14,042 White women aged 50 years and older from a health maintenance organization in the Pacific Northwest of the U.S. Results. The proportion of AI/AN and White women screened for CRC at age 50 was similar (13.3% vs. 14.0%, p =.74). No differences were seen in the type of screening test. Time elapsed to first screening among AI/AN women who were not screened at age 50 did not differ from White women (hazard ratio 1.0, 95% confidence interval 0.8–1.3). Conclusions. Uptake for CRC screening was similar among insured AI/AN and White women, suggesting that when access to care is equal, racial disparities in screening diminish.

Health Literacy and Informed Consent Materials: Designed for Documentation, Not Comprehension of Health Research

Minority populations with health disparities are underrepresented in research designed to address those disparities. One way to improve minority representation is to use community-based participatory methods to overcome barriers to research participation, beginning with the informed consent process. Relevant barriers to participation include lack of individual or community awareness or acceptance of research processes and purposes. These barriers are associated with limited health literacy. To inform recommendations for an improved consent process, we examined 97 consent documents and 10 associated Institutional Review Board websites to determine their health literacy demands and degree of adherence to principles of community-based research. We assessed the reading level of consent documents and obtained global measures of their health literacy demand by using the Suitability and Comprehensibility Assessment of Materials instrument. Although these documents were deemed suitable as medical forms, their readability levels were inappropriate, and they were unsuitable for educating potential participants about research purposes. We also assessed consent forms and Institutional Review Board policies for endorsement of community-based participatory principles, finding that very few acknowledged or adhered to such principles. To improve comprehension of consent documents, we recommend restructuring them as educational materials that adhere to current health literacy guidelines.

Spirituality and mental health status among Northern Plain tribes

ABSTRACT Spirituality measures often show positive associations with preferred mental health outcomes in the general population; however, research among American Indians (AIs) is limited. We examined the relationships of mental health status and two measures of spirituality – the Midlife Development Inventory (MIDI) and a tribal cultural spirituality measure – in Northern Plains AIs, aged 15–54 (n = 1636). While the MIDI was unassociated with mental health status, the tribal cultural spirituality measure showed a significant relationship with better mental health status. Mental health conditions disproportionately affect AIs. Understanding protective factors such as cultural spirituality that can mitigate mental health disorders is critical to reducing these health disparities.