Lack of access to care, funding limitations, cultural, and social barriers are challenges specific to tribal communities that have led to adverse cancer outcomes among American Indians/Alaska Natives (AI/AN). While the cancer navigator model has been shown to be effective in other underserved communities, it has not been widely implemented in Indian Country. We conducted in-depth interviews with 40 AI/AN patients at tribal clinics in Idaho and Oregon. We developed the survey instrument in partnership with community members to ensure a culturally appropriate semi-structured questionnaire. Questions explored barriers to accessing care, perceptions of the navigator program, satisfaction, and recommendations. AI/AN cancer patients reported physical, emotional, financial, and transportation barriers to care, but most did not feel there were any cultural barriers to receiving care. Navigator services most commonly used included decision making, referrals, transportation, scheduling appointments, and communication. Satisfaction with the program was high. Our study provides a template to develop a culturally appropriate survey instrument for use with an AI/AN population, which could be adapted for use with other indigenous patient populations. Although our sample was small, our qualitative analysis facilitated a deeper understanding of the barriers faced by this population and how a navigator program may best address them. The results reveal the strengths and weakness of this program, and provide baseline patient satisfaction numbers which will allow future patient navigator programs to better create evaluation benchmarks.
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Despite the problems associated with analyzing water samples for Giardia cysts and Cryptosporidium oocysts, the data can be very useful if their strengths and weaknesses are understood. Two municipalities in northern Ontario, Temagami and Thunder Bay, both issued boil water advisories for Giardia contamination. Data from these two cities are compared to show that only one municipality experienced a real outbreak, whereas the other did not. The concentration of Giardia cysts was much higher than background during the outbreak at Temagami, and the postoutbreak concentrations of cysts were very similar to the long-term average cyst concentration at Thunder Bay. The waterborne outbreak of giardiasis at Temagami was characterized by consistent positive results from water samples, concentrations two to three orders of magnitude higher than normal, and an obvious increase in the number of cases of giardiasis in the population. No outbreak was experienced at Thunder Bay, but a boil water advisory (BWA) was set in place for more than a year on the basis of a single sample from Loch Lomond in which only two cysts were detected but the sample equivalent volume was low. This gave the impression of a sudden increase in concentration, but 39 of 41 subsequent samples were negative. Additional factors that led to a BWA at Thunder Bay are described, and recommendations are presented to help determine when a BWA is necessary and when it should be rescinded.
The purpose of this article is to report on the development and initial use of a pesticide knowledge test (PKT) specifically designed to evaluate agricultural workers' knowledge of the content mandated by the federal Worker Protection Standard (WPS). The PKT is a 20-item, true-false test, used in a sample of 414 adult and adolescent migrant farmworkers in Oregon. The overall mean score, i.e., number correct, was 15.67(78.4%), with both adults and adolescents demonstrating the most difficulty with questions related to the overall health effects of pesticides. The internal consistency was 0.73, when estimated using a method to correct for small sample sizes. Only six items had less than 70% correct answers. Content validity was achieved by basing the items directly on the Worker Protection Standard; face validity was obtained by having the final version of the test reviewed by a bilingual (English-Spanish) educator familiar with the requirements of the WPS. Overall, adult participants scored better than adolescents, and those with previous pesticide training scored better than those without. There were no differences in scores based on gender or whether the test was taken in English or Spanish; however, participants who spoke indigenous languages scored significantly lower than those who did not. These results indicate that the PKT is a valid, reliable measure of worker knowledge of the content of the WPS, although it does not measure the extent to which that knowledge is actually used in the work setting.
Total alkalinity (AT) is an important parameter for describing the marine inorganic carbon system and understanding the effects of atmospheric CO2 on the oceans. Measurements of AT are limited, however, because of the laborious process of collecting and analyzing samples. In this work we evaluate the performance of an autonomous instrument for high temporal resolution measurements of seawater AT. The Submersible Autonomous Moored Instrument for alkalinity (SAMI-alk) uses a novel tracer monitored titration method where a colorimetric pH indicator quantifies both pH and relative volumes of sample and titrant, circumventing the need for gravimetric or volumetric measurements. The SAMI-alk performance was validated in the laboratory and in situ during two field studies. Overall in situ accuracy was -2.2 ± 13.1 µmol kg(-1) (n = 86), on the basis of comparison to discrete samples. Precision on duplicate analyses of a carbonate standard was ±4.7 µmol kg(-1) (n = 22). This prototype instrument can measure in situ AT hourly for one month, limited by consumption of reagent and standard solutions.
A diverse array of bacterial species, including several potential human pathogens, was isolated from edible crabs collected in cold waters. Crabs collected near Kodiak Island, Alaska, contained higher levels of bacteria than crabs collected away from regions of human habitation. The bacteria associated with the crabs collected near Kodiak included Yersinia enterocolitica, Klebsiella pneumoniae, and coagulase-negative Staphylococcus species; the pathogenicity of these isolates was demonstrated in mice. Although coliforms were not found, the bacterial species associated with the tissues of crabs collected near Kodiak indicate possible fecal contamination that may have occurred through contact with sewage. Compared with surrounding waters and sediments, the crab tissues contained much higher proportions of gram-positive cocci. As revealed by indirect plate counts and direct scanning electron microscopic observations, muscle and hemolymph tissues contained much lower levels of bacteria than shell and gill tissues. After the death of a crab, however, the numbers of bacteria associated with hemolymph and muscle tissues increased significantly. Microcosm studies showed that certain bacterial populations, e.g., Vibrio cholerae, can be bioaccumulated in crab gill tissues. The results of this study indicate the need for careful review of waste disposal practices where edible crabs may be contaminated with microorganisms that are potential human pathogens and the need for surveillance of shellfish for pathogenic microorganisms that naturally occur in marine ecosystems.
Nationally, a greater proportion of American Indians and Alaska Natives (AI/ANs) are diagnosed with advanced-stage cancers compared with non-Hispanic whites. The reasons for observed differences in stage at diagnosis between AI/ANs and non-Hispanic whites remain unclear.
Medicaid, Indian Health Service Care Systems, and state cancer registry data for California, Oregon, and Washington (2001-2008, analyzed in 2014-2015) were linked to identify AI/ANs and non-Hispanic whites diagnosed with invasive breast, cervical, colorectal, lung, or prostate cancer. Logistic regression was used to estimate ORs and 95% CIs for distant disease versus local or regional disease, in AI/ANs compared with non-Hispanic white case patients.
A similar proportion of AI/AN (31.2%) and non-Hispanic white (35.5%) patients were diagnosed with distant-stage cancer in this population (AOR=1.03, 95% CI=0.88, 1.20). No significant differences in stage at diagnosis were found for any individual cancer site. Among AI/ANs, Indian Health Service Care Systems eligibility was not associated with stage at diagnosis.
In contrast to the general population of the U.S., among Medicaid enrollees, AI/AN race is not associated with later stage at diagnosis. Cancer survival disparities associated with AI/AN race that have been observed in the broader population may be driven by factors associated with income and health insurance that are also associated with race, as income and insurance status are more homogenous within the Medicaid population than within the broader population.
Laboratory testing services are presently undergoing dynamic changes in response to a wide range of external factors. Government regulations, reimbursement, and managed care are only a few of the influences affecting the availability of testing services and on-site testing capabilities in hospital, independent, and physician office laboratories. Medical practice changes, marketplace influences, test technologies, and costs also play a role in determining where testing is being performed. To better understand the factors influencing clinical laboratory test volumes and menus and to identify on-site testing deemed essential in physician office laboratories, we gathered information from a network of clinical laboratories in the Pacific Northwest. Questionnaires were sent to 257 Laboratory Medicine Sentinel Monitoring Network participants in March 1996. In the past 2 years, changes in on-site test volumes and test menus have been primarily due to medical practice changes and marketplace influences. When laboratories had a decrease in test volumes or test menu choices, the size of the patient workload and the volumes of test orders have had the greatest impact. Laboratory regulations and managed care contracts have played a role in shifting on-site testing to outside sources; however, these factors did not appear to be primary influences. Only 5% of physician office laboratories identified tests that they believed were essential for optimal patient care but did not perform on-site.
Health care reform strategies proposed by provincial governments include decentralized funding and increased public participation in decision making. These proposals do not give details as to the public participation process, and a number of questions have been raised by the experience of some communities. Which citizens should form the decision-making group? What information do they need? What kinds of decisions should they make? What level of participation should they have? The results of a survey by Abelson and associates (see pages 403 to 412 of this issue) challenge the assumption that "communities" are willing to participate in health-care and social-service decision making. Willingness varied according to the composition of the groups polled, and participants' support for traditional decision makers increased after the complexities of the decision-making process were discussed. However, whereas their study measured willingness to participate at one point in time only, experience gained from Ontario's Better Beginnings, Better Futures project indicates that, given sufficient time, "ordinary" citizens are willing and can acquire the skills needed to decide how resources should be allocated for social services.
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In attempts to contain mental health costs, administrators are increasingly using incentives, competition, and accounting strategies and are creating more complicated financing systems. Yet the costs of these strategies and their impacts on the efficacy and efficiency of mental health services have yet to be studied. The authors compare mental health payment systems in British Columbia and Oregon. In the Canadian system, the patient is isolated from payment, sources of revenue are consolidated at the provincial level, only one payment mechanism per service type is used, health care documentation is oriented more to clinical needs than to reimbursement, and more discretion is delegated to providers. As a result, Canadian overhead costs are substantially less than those in the U.S. Patients have universal access to medical services in the Canadian system, and providers in hospitals, agencies, and individual practices have high incomes with low overhead costs.