CHER team members and affiliates had a strong presence this year at the annual American Public Health Association (APHA) meeting and expo. Presentations included a range of health equity research incorporating northern Arizona’s diverse culture and health issues, health technology, and health issues at the U.S.-Mexico border.
CHER team members and affiliates included: Julie Baldwin, Steven Barger, Timothy Behrens, Ricky Camplain, Emery Eaves, Samantha Sabo, Katharine Sanderson, Grant Sears, Nicolette Teufel-Shone, Robert Trotter, and Jamie Wilson.
Asset-Based Career Pathways with Diné American Indian Students
Carmella Kahn, Diné College; Heather Dreifuss, Diné College; Mark Bauer, Diné College; Nicolette Teufel-Shone, Northern Arizona University; Kathryn Hartzell, Diné College; Jamie Wilson, Northern Arizona University
Background: More American Indian health professionals and researchers are needed to develop culturally relevant health education and for Native Nations to exercise their sovereignty by designing programs and passing policy to achieve health equity through cultural strengths. Yet, for aspiring health professionals on rural reservations, education and training opportunities are limited.
Objective: Diné College (Navajo Nation Tribal College) and Northern Arizona University partnered to build and institutionalize the social and institutional infrastructure needed to enhance the Navajo Nation’s professional public health capacity by training Navajo students, practitioners, and researchers.
Results: This educational pathway uses an asset-based approach, by having participants document their own and their communities’ resilience strategies. The pathway is grounded in the Diné educational philosophy, Są’áh Naagháí Bik’eh Hózhóo (SNBH). SNBH provides principles for protection from life’s imperfections and development of wellbeing.
SNBH is composed of four equal and interdependent components:
- thinking
- planning
- living
- assurance
Through experiential learning opportunities and coursework, the pathway has increased the number of high school students familiar with health related professions, engaged undergraduate students in local research and evaluation activities, and expanded graduate students’ understanding of the socio-cultural factors shaping AI health. Evaluation of project impact is tracked through student enrollment, completed courses, degrees awarded, and student voice documenting factors associated with academic success and application of learned skill sets. Conclusion: Students’ report that the experiential learning and AI focus of the program reinforce their commitment to a career in health/public health service and research.
Engaging Underserved American Indian Communities in Health Equity Research in Rural Northern Arizona: Addressing the Opioid Epidemic and Chronic Pain
Grant Sears, Northern Arizona University; Emery Eaves, Northern Arizona University; Cora Phillips, Northern Arizona University; Julie Baldwin, Northern Arizona University
The community-driven “Involving Native Stakeholders in Pain Research Efforts (INSPiRE)” project, funded by the Patient Centered Outcomes Research Institute (PCORI), focuses on engaging patients, providers, and other stakeholders in health equity research to address opioid addiction and chronic pain in underserved rural, southwest American Indian (AI) communities.
The INSPiRE project was designed to establish a partnership through:
- formation of a community steering committee (CSC) composed of AI community leaders with experience in addiction treatment using traditional healing
- skill-building workshops targeting youth, providers, and the broader community
- a symposium to engage researchers and experts with expertise in pain management and opioid use/misuse to work toward developing a collaborative research agenda
Using the Community Coalition Action Theory (CCAT) as a guiding framework, community-driven workshops focused on assets rather than deficiencies, allowing the community to engage in research design and problem-solving. Workshops were designed to welcome community members to share perspectives on community needs, particularly regarding pain and opioid research. The INSPiRE project built a foundation of collaboration, involving AI communities in every step of the research design process. This presentation describes the first author’s experience as a student intern facilitating community partnership building. We highlight key lessons about the importance of community involvement for working toward health equity in AI communities. Uniting stakeholders in working toward a common cause, the INSPiRE project is an example of a community-driven effort to collaboratively work toward tailored and relevant ways to address opioid overuse and pain in AI communities.
Racial/ethnic and gender differences in substance use treatment utilization in prisons and jails versus non-correctional settings
George Pro, University of Iowa, College of Public Health; Paul A. Gilbert, University of Iowa
Background: Racial/ethnic minorities and males experience high rates of incarceration, and these relationships are more pronounced among individuals with substance use problems. Substance use treatment utilization in jail or prison is broadly associated with improved health, but disparities in the use of treatment in correctional settings are not well documented. This paper aims to measure the effects of race/ethnicity and gender on treatment utilization in prison or jail versus treatment in non-correctional settings.
Methods: We used data obtained in the National Survey on Drug Use and Health (2010-2014) to examine a sample of individuals with past-year DSM-IV substance abuse or dependence who also sought any treatment for their problem in the past year (n=2311). We used bivariate and multiple logistic regression to model the effect of race/ethnicity and gender on treatment utilization in jail or prison in the past year. We also used customized contrast tests to model an interaction between race/ethnicity and gender. RESULTS Twelve percent of the sample utilized substance use treatment in a jail or prison in the past year. In our adjusted model, African Americans had significantly higher odds of utilizing treatment in a prison or jail (OR=2.55; 95% CI=1.2, 5.6; p=0.01) compared to Whites. No other racial/ethnic minority group differed from Whites. The race-by-gender interaction was also significant, such that African American women had significantly lower odds of utilizing treatment (OR=0.16; 95% CI=0.1, 0.6; p<0.01) in a prison or jail compared to African American men.
Conclusion: African Americans were more likely than Whites to receive treatment in a prison or jail, and this relationship was largely driven by African American men. Treatment in prisons and jails may be strengthened by tailoring services to meet the needs of African American men.
County-Level Variation in Education Gradients for Poor Mental Health: A Population Based Study in Rural Northern Arizona
Steven D. Barger, Northern Arizona University; Julie Baldwin, Northern Arizona University; Ricky Camplain, Northern Arizona University; Robert Trotter, Northern Arizona University; Katharine Sanderson, Northern Arizona University
Background: Health inequity is often characterized using socioeconomic indicators such as education. However, education-related inequities may also be conditioned by geography, a phenomenon that is less well understood in rural settings.
Objectives: To examine the co-occurrence of poor mental health and low educational achievement across six rural northern Arizona counties.
Methods: To accrue a sufficient sample size we pooled five years (2011-2015) of Arizona Behavioral Risk Factor Surveillance System (BRFSS) data, a probability telephone survey of noninstitutionalized adults. We restricted our analyses to Apache, Navajo, Coconino, Gila, Yavapai and Mohave counties (N = 8,568). Together these counties are geographically larger than 30 US states but are modestly populated (53,000-222,000 residents per county). Poor mental health was defined as 14 or more of the last 30 days having problems with stress, depression and/or emotional problems. We estimated poor mental health prevalence across counties. Within county, we used logistic regression to evaluate the association of education with poor mental health. All analyses used pooled 5-year sample weights and incorporated the complex survey design.
Results: Poor mental health prevalence was similar across counties (range 10-14%; between county comparison p’s > 0.29). Among residents of all six counties, relative to those with less than a high school education, persons with a high school degree (OR = 0.62, 95%CI 0.43, 0.89), some college (OR=.57, 95%CI 0.40, 0.82), or college or higher education (0.33; 95%CI 0.23, 0.49) had lower odds of poor mental health. In absolute terms, poor mental health prevalence by education was 18%, 12%, 11% and 7%, respectively. Within county analyses showed that low education was associated with poorer mental health in Yavapai and Apache counties but not in the other four counties. The magnitude of these educational differences were substantial – among those with a high school education or more, poor mental health prevalence was 9% in in Apache (95%CI 6, 13) and Yavapai (95%CI 7, 11) counties. For those with less than a high school education, poor mental health prevalence was 29% (95%CI 17, 45) and 33% (95%CI 22, 47), respectively.
Conclusion: Substantial educational disparities in poor mental health were observed in rural northern Arizona but were geographically dependent. These data underscore the importance of geography in understanding education-based mental health inequities in the rural southwest.
Caregiving on the Hopi Reservation: The Hopi Female Caregiver Experience
Felina Cordova-Marks, UofA College of Public Health and College of Medicine; Nicolette Teufel-Shone, UofA College of Public Health; Robin Harri, University of Arizona; Beatrice Norton, Hopi Office of Aging and Adult Services
American Indian (AI) caregivers have been excluded from national surveying efforts on family caregiving. From the 2012 Cancer and Chronic Disease Survey on the Hopi Reservation, the prevalence of caregiving is 20% among the Hopi Tribe. Methods: A survey was built in Epi Info© to determine activities associated with caregiving including amount and type of care being provided, difficulties, caregiver health, support services for caregiver desired and perception of stress and resiliency. Stress and resiliency were examined using the Cohen stress scale score and the CD-RISC scale. This survey was administered on an iPad by a trained Hopi interviewer to self-identified caregivers of a family member on the Hopi Reservation.
Results: Forty-four female Hopi caregivers were surveyed. Average age was 59 years, with care provided for an average of 5.48 years. The majority of caregivers were caring for parents, average age of 83 years and needing care for dementia, cancer, cardiovascular disease, and diabetes. Caregivers provided transportation, household management, and medical related care. Caregivers experienced difficulties such as not having enough time for family/friends/selves, and financial burden. Caregivers would like additional services, i.e. training on caring for their relative, information managing their emotional/physical stress, and support groups. Caregiver’s responses aligned with an average stress score and high resiliency.
Discussion: Hopi caregivers balance personal, emotional and financial demands of caregiving. The juxtaposition of their moderate stress score and high resiliency should be examined relative to cultural expectations and could guide support service for AI and non-AI caregivers.
Community Health Representatives: Tribal Program Perspectives on Workforce Policy and Sustainability
Kim Russell, Arizona Advisory Council on Indian Health Care; Brooke Bender, Hualapai Health Department; Joyce Hamilton, Hopi Health Department; Mae-Gilene Begay, Navajo Nation Division of Health; Preeo Johnson, White Mountain Apache – CHR Program; JT Nashio, White Mountain Apache Tribe; Laurie Joshweseoma, Hopi Tribe; Michael Allison, Arizona Department of Health Services; Yanitza Soto, Arizona Department of Health Services Bureau of Tobacco & Chronic Disease; Alida Montiel, Inter Tribal Council of Arizona, Inc.; Kelly Eagle, Indian Health Services – Phoenix Area Office; Samantha Sabo, Northern Arizona University
Community Health Representatives (CHRs): With an estimated workforce of 1,700 representing 264 tribes, CHRs are characterized as community leaders who share the language and life experiences of the community members they serve. As members of the community, educators and advocates, CHRs are familiar with the language and the unique cultural aspects of their patient’s lives.
Objective: In Arizona, CHRs account for 30% of the total CHW workforce. A total of 19 Tribes manage and operate their own CHR Program. Methods: Since 2015, CHR Programs have come together for annual CHR Policy Summits to dialogue and plan for the unique issues and opportunities regarding CHR sustainability and advancement and the need for inclusion of CHRs in state and national level dialogue regarding workforce certification and financing.
Results: As a roundtable, CHRs from four sovereign nations and distinct CHR Programs will discuss policy initiatives and advocacy strategies unique to the CHR workforce including: (1) Mechanisms for inclusive collaboration at the tribal, state, and national levels; (2) State and national CHR certification and the national role out of the Indian Health Service Community Health Aide Program; (3) Leveraging multiple CHR programs to shape CHR scope of practice, and workforce policy, including emerging mechanisms for reimbursement and financial sustainability.
Conclusion: CHRs are major contributors to the health and wellbeing of rural and urban American Indian communities and are critical to the advancement of the broader CHW workforce nationally.
Arizona Community Health Workers Association’s Journey Towards a CHW Voluntary Certification
Floribella Redondo, Arizona Community Health Workers Association; Maia Ingram, University of Arizona; Jill de Zapien, University of Arizona; Samantha Sabo, Northern Arizona University; Yanitza Soto, Arizona Department of Health Services Bureau of Tobacco & Chronic Disease; Lorena Verdugo, Mexican Consulate – Tucson; Kathryn Margaret Tucker, Arizona Prevention Research Center
Background: Community Health Workers (CHWs) in Arizona have a long history of building a strong workforce based on community advocacy and social justice. Over the past four years, the Arizona CHWs Association (AzCHOW) has engaged in a process to elevate the CHW professional recognition and sustainability by developing a path for CHW Voluntary Certification. Methods: AzCHOW developed a collaborative partnership with the Arizona Department of Health Services and the Arizona CHW Workforce Coalition, made up of stakeholders from across the state. With continuous feedback from CHW membership, AZCHOW developed an infrastructure for voluntary certification that includes CHW core competency review, CHW training approval, and web-based application and registry. Concurrently, AzCHOW engaged in the political process of legislating CHW voluntary certification. Results: Our presentation will provide a reflection of the legislative process, complications we encountered in building a statewide movement, and implications for the CHW workforce. Key to our success was engagement of Community Health Representatives. While CHW certification has the potential to vastly improve the welfare of the workforce, we recognize that we are operating in a dynamic environment and shifting political landscape. We will highlight our experience negotiating the political and economic interests at play in health care and the important role CHWs should and must play when it comes to their professional future. Conclusion: AzCHOW’s successful campaign for voluntary certification in the Arizona legislature is the culmination of broad efforts to gain consensus among a diverse CHW workforce. Our experience offers lessons to CHWs in other states.
YPAR Photovoice Findings: Factors that Influence Adolescent Substance Use on the U.S.-Mexico Border
Elizabeth Salerno Valdez, University of Arizona; Samantha Sabo, Northern Arizona University; Josephine Korchmaros, University of Arizona; David O. Garcia, University of Arizona, Mel and Enid Zuckerman College of Public Health; Nathan Stupiansky, University of Arizona, Arizona Health Sciences; Scott Carvajal, University of Arizona, Mel and Enid Zuckerman College of Public Health
Mexican-origin adolescents living on the U.S.-Mexico border experience higher rates of substance use-related problems compared to non-border Mexican-origin population and their non-Hispanic white counterparts. The unique environmental context of the U.S.-Mexico border may exacerbate the risk of substance use for adolescents residing there, specifically exposure to nearby drug trafficking, cross-border mobility, and increased availability of alcohol and tobacco, and high unemployment. However, the sociocultural characteristics of the border region may be protective against substance use among adolescents, such as the presence of Mexican culture, social support, and religiosity. The unique characteristics of the border region warrants the need for substance use research that engages the adolescents that exist and interact in this environment. The investigator and a local youth health coalition engaged in Youth Participatory Action Research using Photovoice to examine the perceived factors that increase risk of, or protect against, substance use among adolescents living at the border. Photovoice is a community-based participatory research method wherein participants communicate their life’s experiences through photography. The youth coalition identified border-bound risk factors for adolescent substance use, including poverty and unemployment, disordered neighborhood, the normalization of drug trafficking, the normalization of substance use, and cross-border access to substances. Sociocultural protective factors include living in a close-knit community, strong social support systems, and involvement in sports. This study provides YPAR-informed data that fill a critical gap in knowledge regarding the factors that influence adolescent substance use in the border region, which will inform future prevention and risk reduction efforts with border adolescents.
Using Youth Participatory Action Research and Photovoice to Examine Adolescent Substance Use on the U.S.-Mexico Border
Alejandro Duarte, Douglas High School; Elizabeth S. Valdez, University of Arizona; Samantha Sabo, Northern Arizona University; David O. Garcia, University of Arizona, Mel and Enid Zuckerman College of Public Health; Josephine Korchmaros, University of Arizona; Scott Carvajal, University of Arizona, Mel and Enid Zuckerman College of Public Health
Background: The risk of substance use might be exacerbated for adolescents residing on the U.S.-Mexico. Influencing factors include drug trafficking, cross-border access to drugs and alcohol, high rates of poverty and unemployment, and border stressors including militarization and perceived discrimination. The unique characteristics of the border region warrant the need for substance use research that engages adolescents who exist and interact in this environment. Methods: We describe the conceptualization, implementation, and community-level outcomes of the Youth Participatory Action Research (YPAR) project conducted by the Cochise County Youth Health Coalition (CCYHC) and the principal investigator. YPAR provides youth with the opportunity to study social problems affecting their lives and to determine actions to solve these problems. The research team used the Photovoice Process to teach CCYHC members to use photography as a research method to document what they perceive to be the environmental factors that increase risk of and/or protect against adolescent substance use in their border community.
Results: CCYHC utilized their collective knowledge garnered from their research to:
- contribute to the development of the culturally- and regionally responsive Border Adolescent Substance Use Survey
- hold a community forum to present their research findings
- develop local and state policy recommendations
Conclusion: This study provides evidence for the use of YPAR and Photovoice as innovative strategies to examine adolescent health issues from the perspective of the population most affected. Further, to our knowledge, this is the first YPAR study for substance use prevention ever conducted on the U.S.-Mexico border.
Deporting youth: Abuse of due process for unaccompanied minors on the U.S.-Mexico Border
Kiera Coulter; University of Arizona; Katelyn Chisholm, University of Arizona; Samantha Sabo, Northern Arizona University; Daniel Martínez, University of Arizona; Jeremy Slack, University of Texas El Paso
Over 13,000 minors were deported from the United States to Mexico in 2016. While a past study demonstrated that Mexican adults frequently experienced incidents of abuse when apprehended and deported by U.S. immigration officials, abuse of deported minors had not been studied. For this study we surveyed 97 recently deported unaccompanied minors about their experiences crossing the border, their treatment by U.S. authorities and their mental health in two border cities. Each survey contained 99 questions that were conducted face-to-face in youth shelters over the Mexican border. We found multiple examples of physical abuse by U.S. authorities against unaccompanied minors, as well as issues in due process and the return of personal documents. More oversight and changes in policy could lead to better outcomes for unaccompanied minors.
Remaining Need for Human Contact to Make E-Health Programs Successful
DeAnne Turner, University of South Florida; Elizabeth Lockhart, University of South Florida; M. Margaret Dolcini, Oregon State University; Robert Glueckauf, Florida State University College of Medicine; Wei Wang, University of South Florida; Celia M. Lescano, University of South Florida; Julie Baldwin, Northern Arizona University; Stephanie Marhefka, University of South Florida, College of Public Health
Background: eHealth programs for people living with HIV (PLH) have emerged in both research and practice. An advantage of eHealth programs is the ability to reach a large number of people within a broad geographic range at a low cost; to do this, wide-spread systems for dissemination and implementation are needed.
Methods: In-depth semi-structured interviews were conducted with 24 PLH in the southeastern US. Via structural codes and thematic analysis, key considerations for dissemination and preferred modes of eHealth program dissemination were identified. Results: When asked about potential avenues for learning about eHealth programs for PLH, most suggested referral from non-technology-based sources (e.g. care team member, group meetings, flyers). Care team staff referrals were the preferred way of learning about eHealth programs – resulting in statements such as “[If my doctor referred me to an eHealth program] I definitely would like it ‘cuz she never have told me nothing wrong.“ Although recruitment via social media was considered acceptable, several participants noted that if they saw a flyer or advertisement they would need to confirm its authenticity with a care team member (“Because they put anything [legitimate or not] on Facebook”).
Conclusions: Despite many eHealth programs being conducted online, internet-based advertisement often raised skepticism–leading many participants to confirm programs’ legitimacy through a trusted source. Healthcare staff were deemed reliable referral/confirmation sources regarding eHealth programs, and programs recommended by these professionals were considered likely to be helpful. Dissemination and implementation strategies for care team referral to eHealth programs should be tested.
Living with HIV in the Age of Technology: Perceptions of Online Dating
DeAnne Turner, University of South Florida; Elizabeth Lockhart, University of South Florida; Shanda Vareen, University of South Florida; Rea Rupani, University of South Florida; Celia M. Lescano, University of South Florida; Robert Glueckauf, Florida State University College of Medicine; Wei Wang, University of South Florida; M. Margaret Dolcini, Oregon State University; Julie Baldwin, Northern Arizona University; Stephanie Marhefka, University of South Florida, College of Public Health
Background: Online dating is increasingly common. For people living with HIV (PLH), online dating may impact traditional methods of HIV disclosure and discussion of safer sex. We investigated factors associated with online dating, as well as views of online dating among PLH. Methods: This mixed methods analysis included logistic regression analyses (N=1252) and interviews (analyzed thematically; n=24) with PLH. Results: Few survey participants (n=204;16.3%) reported previously online dating. In logistic regression, decreasing age (aOR=.97[.95-.98]) and categorization as a man who has sex with men ((MSM); aOR=9.25[4.61-18.56]) were significantly associated with online dating, holding geography, ethnicity, race, and gender constant. In a sub-analysis of heterosexual participants, age did not impact online dating. In interviews, participants contradicted survey results, stating they believed more than 16% of PLH use online dating. They thought others might be reluctant to disclose online dating because of: a) negative perceptions of online dating; and b) anticipated judgments about dating while HIV-positive. Participants themselves were reluctant to share their experience with online dating-not admitting past online dating until later in interviews. Consistent with prior studies, some MSM stated online dating may facilitate disclosure prior to meeting in-person. Participants stated sites specifically designed for PLH could “make it easier” to date online; others thought such sites had too few PLH participating in their region. Conclusions: PLH who are older and non-MSM may be reluctant to disclose online dating. There is a need to acknowledge associated stigma and normalize online dating to increase disclosure and enable richer information-gathering in research.
Using the Life Course Perspective to Explore Maternal and Child Health Risk and Protective Factors through Community-Based Participatory Research
DeAnne Turner, University of South Florida; Elizabeth Lockhart, University of South Florida; Shanda Vareen, University of South Florida; Rea Rupani, University of South Florida; Celia M. Lescano, University of South Florida; Robert Glueckauf, Florida State University College of Medicine; Wei Wang, University of South Florida; M. Margaret Dolcini, Oregon State University; Julie Baldwin, Northern Arizona University; Stephanie Marhefka, University of South Florida, College of Public Health
Abraham Salinas, University of South Florida, College of Public Health; Lindsey King, University of Florida; Hamisu Salihu, Baylor College of Medicine; Ronee Wilson, University of South Florida; Estrellita “Lo” Berry, REACHUP Inc.; Deborah Austin, REACHUP, Inc.; Susan Nash, Baylor College of Medicine; Kenneth Scarborough, Operation New Hope; Evangeline Best, REACHUP, Inc.; Lillian Cox; Georgette King; Carrie Hepburn, Tampa Bay Healthcare Collaborative; Conchita Burpee; Richard Briscoe; Julie Baldwin, Northern Arizona University
Little is known about the patterns of risk and protective factors experienced by communities of color and how diverse community contexts shape the health trajectory of women from the early childhood period to the time of their pregnancies. The life course perspective, a valuable theoretical framework for investigating racial disparities in birth outcomes, examines the cumulative exposure of risk and protective factors throughout the life span. We aimed to identify risk and protective factors over the life course that contribute to maternal and child health from the perspective of community members residing in low income urban areas. Guided by the life course perspective, we conducted 10 community-based participatory focus groups with residents from targeted areas in Tampa, Florida. A total of 78 residents participated in the focus groups. Protective factors for children and adolescents were positive role models, nutrition, and community support; risks included obesity, lack of physical activity, and low self-esteem. Pregnancy protective factors included self-esteem, spirituality, pregnancy support, good nutrition, prenatal care, and community resources; risks included stress, lack of physical activity, healthcare issues, lack of social support, and lack of father involvement. Outside the context of pregnancy, protective factors for women were self-esteem, spirituality, social support, community resources, and societal factors; risks were low health literacy and financial problems. Multiple risk and protective factors contribute to maternal and child health across the life span in low-income communities. The intersection of risk and protective factors in different life periods must be considered in developing effective policies and interventions.
Research reported in this publication was supported by the National Institute On Minority Health And Health Disparities of the National Institutes of Health under Award Number U54MD012388. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.