Choice of home blood pressure monitoring device: the role of device characteristics among Alaska Native and American Indian peoples

Background: Home blood pressure monitoring (HBPM) is an effective tool in treatment and long-term management of hypertension. HBPM incorporates more data points to help patients and providers with diagnosis and management. The characteristics of HBPM devices matter to patients, but the relative importance of the characteristics in choosing a device remains unclear. Methods: We used data from a randomized cross-over pilot study with 100 Alaska Native and American Indian (ANAI) people with hypertension to assess the choice of a wrist or arm HBPM device. We use a random utility framework to evaluate the relationship between stated likely use, perceived accuracy, ease of use, comfort, and participant characteristics with choice of device. Additional analyses examined willingness to change to a more accurate device. Results: Participants ranked the wrist device higher compared to the arm on a 5-point Likert scale for likely use, ease of use, and comfort (0.3, 0.5, 0.8 percentage points, respectively). Most participants (66%) choose the wrist device. Likely use (wrist and arm devices) was related to the probability of choosing the wrist (0.7 and − 1.4 percentage points, respectively). Independent of characteristics, 75% of participants would be willing to use the more accurate device. Ease of use (wrist device) and comfort (arm device) were associated with the probability of changing to a more accurate device (− 1.1 and 0.5 percentage points, respectively). Conclusion: Usability, including comfort, ease, and likely use, appeared to discount the relative importance of perceived accuracy in the device choice. Our results contribute evidence that ANAI populations value accurate HBPM, but that the devices should also be easy to use and comfortable to facilitate long-term management.Sociolog

Coastal natural and nature-based features: international guidelines for flood risk management

Natural and nature-based features (NNBF) have been used for more than 100 years as coastal protection infrastructure (e.g., beach nourishment projects). The application of NNBF has grown steadily in recent years with the goal of realizing both coastal engineering and environment and social co-benefits through projects that have the potential to adapt to the changing climate. Technical advancements in support of NNBF are increasingly the subject of peer-reviewed literature, and guidance has been published by numerous organizations to inform technical practice for specific types of nature-based solutions. The International Guidelines on Natural and Nature-Based Features for Flood Risk Management was recently published to provide a comprehensive guide that draws directly on the growing body of knowledge and practitioner experience from around the world to inform the process of conceptualizing, planning, designing, engineering, and operating NNBF. These Guidelines focus on the role of nature-based solutions and natural infrastructure (beaches, dunes, wetlands and plant systems, islands, reefs) as a part of coastal and riverine flood risk management. In addition to describing each of the NNBF types, their use, design, implementation, and maintenance, the guidelines describe general principles for employing NNBF, stakeholder engagement, monitoring, costs and benefits, and adaptive management. An overall systems approach is taken to planning and implementation of NNBF. The guidelines were developed to support decision-makers, project managers, and practitioners in conceptualizing, planning, designing, engineering, implementing, and maintaining sustainable systems for nature-based flood risk management. This paper summarizes key concepts and highlights challenges and areas of future research

Prenatal alcohol exposure among Alaska Native/American Indian infants

Background. Recent reports indicate a decline in rates of Fetal Alcohol Syndrome (FAS) among Alaska Native and American Indian (AN/AI) infants. Nevertheless, AN/AI infants remain disproportionately impacted by the effects of prenatal alcohol exposure.Methods. AN/AI pregnant women in their 3rd trimester completed a questionnaire on demographic data and the amount and frequency of their alcohol consumption in the month prior to conception and during pregnancy. Differences across demographics and trimesters were tested with the Chi-square, Fisher's exact or McNemar's test as appropriate.Results. Of the 125 participants, 56% (n = 71) reported no alcohol consumption in the 1st through 3rd trimesters of pregnancy; 30% (n = 38) of the 125 participants also reported no alcohol consumption in the month before pregnancy. Of the 43% (n = 54) who reported consuming alcohol during pregnancy (1st, 2nd and/or 3rd trimester), most (35%) reported alcohol use only in the 1st trimester. Binge drinking in the 1st or 2nd trimester was reported amongst 20% (n = 25) of participants with an additional 18% (n = 29) reporting binge drinking in the month prior to pregnancy. Women who reported pre-conception binge drinking were significantly more likely to report binge drinking during their 1st trimester (p < 0.0001) and 2nd trimester (p < 0.0001). A history of tobacco use (p = 0.0403) and cigarette smoking during pregnancy (p < 0.0001) were also associated with binge drinking during pregnancy.Conclusion. Among study participants, reported use of alcohol was primarily limited to pre-conception and the 1st trimester, with a dramatic decrease in the 2nd and 3rd trimesters. Prevention programmes, such as the Alaska FAS Prevention Project, may have contributed to observed decreases in the 2nd and 3rd trimesters. Additional study and focus on pre-conception, the 1st trimester and binge drinking, as well as tobacco use might augment Fetal Alcohol Spectrum Disorder prevention efforts

Chronic disease and impairment among Alaska native elders : the Alaska Education and Research Towards Health (EARTH) study

Background: Chronic diseases and impairments are prevalent among older Americans. However, prevalence data for Alaska Native (AN) elders are limited, with estimates usually extrapolated from national studies in which AN elders may not be well-represented. The aim of this study was to describe the prevalence of selected chronic diseases, impairments, and measured medical risk factors among a large community sample of AN elders. Methods: Design, setting, and participants. A community-based cross-sectional study of baseline information from 656 AN elders aged 55 years or over who participated in the Alaska Education and Research Towards Health (EARTH) Study, March 2004 to August 2006. Measurements. Self-reported lifetime prevalence of 17 doctor-diagnosed chronic diseases, and point prevalence of vision, hearing, oral, and general health impairment were estimated from data collected using audio computer-assisted self-administered questionnaires. In addition, height, weight, blood pressure, fasting blood lipids, and fasting blood glucose levels were measured.Results: The four most prevalent chronic diseases among AN elders were high blood pressure (55%), arthritis (49%), high cholesterol (42%), and adult bone fracture/break (35%). The median number of chronic diseases reported was three (inter-quartile range, 2 to 5). The prevalence of self-reported vision impairment was 15%, hearing impairment 18%, and having had all natural teeth removed 25%. Almost 50% were obese. High blood pressure (systolic &ge; 140 mm Hg and/or diastolic &ge; 90 mm Hg) was measured in 23%, high low density lipoprotein (LDL) cholesterol (&ge; 130 mg/dL) in 39%, and high fasting plasma glucose (&gt; 125 mg/dL) in 9%. Obesity was more prevalent among women than men. There were also significant regional differences in rates of obesity and high LDL cholesterol.Conclusion: These data may be useful in public health programs and health services planning

The Impact of Patient and Provider Factors on Depression Screening of American Indian and Alaska Native People in Primary Care

Introduction : The US Preventive Services Task Force recommends routine depression screening in primary care, yet regular screening does not occur in most health systems serving Alaska Native and American Indian people. The authors examined factors associated with administration of depression screening among Alaska Native and American Indian people in a large urban clinic. Methods : Medical records of 18 625 Alaska Native and American Indian adults were examined 1 year after implementation of a depression screening initiative. Multilevel logistic regression models examined associations between patient and provider factors and administration of the Patient Health Questionnaire–9. Results : Forty-seven percent of patients were screened. Women were more likely than men to be screened (50% vs 43%, P < .001). Increased screening odds were associated with older age, increased service use, and chronic disease ( P < .001) but not with substance abuse disorders or prior antidepressant dispensation. Women previously diagnosed with depression had higher odds of screening ( P = .002). Men seen by male providers had higher odds of screening than did men seen by female providers ( P = .040). Screening rates peaked among providers with 2 to 5 years of employment with the clinic. Limitations : Cross-sectional analysis of medical record data was of unknown reliability; there were limited sociodemographic data. Conclusions : Even with significant organizational support for annual depression screening, primary care providers systematically missed men and patients with infrequent primary care visits. Outreach to male patients and additional supports for primary care providers, especially in the first years of practice, may improve screening and treatment for depression among Alaska Native and American Indian people

Self-Determination in Health Research: An Alaska Native Example of Tribal Ownership and Research Regulation

Alaska Native (AN) and American Indian (AI) people are underrepresented in health research, yet many decline to participate in studies due to past researcher misconduct. Southcentral Foundation (SCF), an Alaska Native-owned and operated health care organization, is transforming the relationship between researchers and the tribal community by making trust and accountability required features of health research in AN/AI communities. In 1998, SCF assumed ownership from the federal government of health services for AN/AI people in south central Alaska and transformed the health system into a relationship-based model of care. This change reimagines how researchers interact with tribal communities and established community oversight of all health research conducted with AN/AI people in the region. We describe the SCF research review process, which requires tribal approval of the research concept, full proposal, and dissemination products, as well as local institutional review board approval, and a researcher-signed contract. This review evaluates research through the lens of tribal principles, practices, and priorities. The SCF example provides a framework for other tribes and organizations seeking to reshape the future of health research in AN/AI communities

Depression and type 2 diabetes among Alaska Native primary care patients

Objectives: To assess whether type 2 diabetes mellitus (DM2) and DM2 complications are associated with presence and severity of depression among Alaska Native and American Indian people (AN/AIs). Design: Retrospective, cross-sectional analysis of medical records. Setting: Southcentral Foundation Primary Care Center (SCF-PCC) in Anchorage, Alaska. Participants: Total of 23,529 AN/AI adults. Primary Outcome Measures: Patient Health Questionnaire (PHQ) scores (0-9 negative, 10-14 mild, 15-19 moderate, 20+ severe) and DSM-IV depression diagnosis. Results: DM2 prevalence was 6% (n=1,526). Of those with DM2, 19% (n=292) had one or more DM2 complications and average HbA1c was 7.1%. Prevalence of depression diagnosis was similar between AN/AIs with and without DM2 (P=.124). Among those screened for depression (n=12,280), there were similar rates of PHQ severity between those without and with DM2; respectively 4% (n=452) vs 4% (n=42) mild, 4% (n=404) vs 3% (n=29) moderate, and 4% (n=354) vs 4% (n=38) severe. In multivariable logistic regression, DM2 was not associated with PHQ severity (OR 1.02, 95% CI 0.81-1.27) or depression diagnosis (OR 1.27, 95% CI 1.00-1.62). Increased odds of depression and higher depression severity were associated with female sex, younger age, being unmarried, substance abuse/dependence, and increased ambulatory visits. Depression was associated with number of other chronic conditions among AN/AIs with DM2 but not with number of complications. Conclusions: Presence and severity of depression among AN/AI primary care patients was not significantly associated with DM2 nor DM2 complications, despite a slightly higher rate of depression diagnosis among those with DM2

Tribal implementation of a patient-centred medical home model in Alaska accompanied by decreased hospital use

Background. Between 1995 and 1998, tribally owned Southcentral Foundation (SCF) incrementally assumed responsibility from the Indian Health Service (IHS) for primary care services on the Alaska Native Medical Center (ANMC) campus in Anchorage, Alaska. In 1999, SCF began implementing components of a Patient-Centered Medical Home (PCMH) model to improve access and continuity of care. Objective. To evaluate hospitalisation trends before, during and after PCMH implementation. Design. Time series analysis of aggregated medical record data. Methods. Regression analysis with correlated errors was used to estimate trends over time for the percent of customer-owners hospitalised overall and for specific conditions during 4 time periods (March 1996&#x2013;July 1999: SCF assumes responsibility for primary care; August 1999&#x2013;July 2000: PCMH implementation starts; August 2000&#x2013;April 2005: early post-PCMH implementation; May 2005&#x2013;December 2009: later post-PCMH implementation). Analysis was restricted to individuals residing in Southcentral Alaska and receiving health care at ANMC. Results. The percent of SCF customer-owners hospitalised per month for any reason was steady before and during PCMH implementation, declined steadily immediately following implementation and subsequently stabilised. The percent hospitalised per month for unintentional injury or poisoning also declined during and after the PCMH implementation. Among adult asthma patients, the percent hospitalised annually for asthma declined prior to and during implementation and remained lower thereafter. The percent of heart failure patients hospitalised annually for heart failure remained relatively constant throughout the study period while the percent of hypertension patients hospitalised for hypertension shifted higher between 1999 and 2002 compared to earlier and later years. Conclusion. Implementation of PCMH at SCF was accompanied by decreases in the percent of customer-owners hospitalised monthly for any reason and for unintentional injury and in the percent of asthma patients hospitalised annually for asthma. Increased accessibility to empanelled care teams may have contributed to decreased need for hospitalisation

Formative evaluation to assess communication technology access and health communication preferences of Alaska Native people

Objective:Information technology can improve the quality, safety, and efficiency of healthcare delivery by improving provider and patient access to health information. We conducted a nonrandomized, cross-sectional, self-report survey to determine whether Alaska Native and American Indian (AN/AI) people have access to the health communication technologies available through a patient-centered medical home. Methods: In 2011, we administered a self-report survey in an urban, tribally owned and operated primary care center serving AN/AI adults. Patients in the center’s waiting rooms completed the survey on paper; center staff completed it electronically. Results: Approximately 98% (n = 654) of respondents reported computer access, 97% (n = 650) email access, and 94% (n = 631) mobile phone use. Among mobile phone users, 60% had Internet access through their phones. Rates of computer access (p = .011) and email use (p = .005) were higher among women than men, but we found no significant gender difference in mobile phone access to the Internet or text messaging. Respondents in the oldest age category (65–80 years of age) were significantly less likely to anticipate using the Internet to schedule appointments, refill medications, or communicate with their health care providers (all p &lt; .001). Conclusion:Information on use of health communication technologies enables administrators to deploy these technologies more efficiently to address health concerns in AN/AI communities. Our results will drive future research on health communication for chronic disease screening and health management.