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Upcoming Events
Webinar: The Promotion of Health Professions as a Workforce Development Strategy in Indian Country
June 25, 2014
3:00-4:00 pm EST
 
Join the webinar to learn more about the basic tenets of workforce development and about a specific example of a healthcare workforce development program in Native communities, the Tribal Health Profession Opportunity Grants (HPOG) Program.

by the end of this webinar, participants will be able to:

  

[1] Describe the principal elements of a workforce development program;

[2] Understand the intent and design of the Tribal HPOG program, and strategies designed to facilitate educational and employment attainment among low-income tribal students; and

[3] Consider strategies that they could adopt in their own communities to engage, support, and train health professions students.

 

Pre-Registration is not required. 

Dial-in Information:

1-866-215-5504

Passcode: 9287393

 

Click Here for the AdobeConnect Link.

 

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Free HIV Testing Events at Select Walgreens Locations in More Than 140 Cities 
June 26-28, 2014

In support of National HIV Testing Day, June 27, Walgreens and Greater Than AIDS have united in response to the domestic AIDS epidemic and are teaming with health departments and local AIDS service organizations across the country to encourage community members to take advantage of free HIV testing. 

For more information on participating locations and testing hours, visit: the Greater Than AIDS website. 

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CDC Tribal Advisory Committee Meeting
Aug. 12-14, 2014
Traverse City, Michigan
 
The Centers for Disease Control and Prevention (CDC) have announced the next face-to-face meeting of the Tribal Advisory Committee (TAC). The meeting will be hosted by the Tribes of the Bemidji Area and will be held at the Grand Traverse Resort and Spa by Traverse City, Michigan. The CDC will be sending out a Dear Tribal Leader Letter soon. This is a good opportunity to consult with Tribal leaders about challenges and successes with health and public health systems and programming, funding, access to information and data, and other related topical areas in order to funnel this information to the official Area TAC representative. As the agenda has not been published yet, it is not known what portions of the meeting will be closed and what will be open, however, attendance is encouraged and a wonderful opportunity to provide live testimony and to listen to the testimony of others.
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NIHB 31st Annual Consumer Conference 
Native Youth Health Summit 
 
 
The NIHB's 2014 Native Youth Health Summit will be held September 4-9, 2014  in Window Rock, New Mexico.  With local support from the Navajo Nation, the Summit will provide a traditional and cultural experience for the youth.  Participants will be given the tools to voice their opinions and tell their personal stories about health issues their Tribal Communities through the digital storytelling project by the Healthy Native Communities Partnership.  A red carpet event will be held on the last day of the summit, coinciding with the kick off to the Annual Consumer Conference, where the youth will showcase their stories.  This Summit is an opportunity for Native youth to build relationships with others across the country with the mission of expanding the knowledge of the health & mental health disparities 
throughout Indian Country and empowering the Native youth voice to be a force for change for a healthier future.
 
NIHB's Annual Consumer Conference will be held the rest of the week, from September 8-11, 2014, in Albuquerque, New Mexico. This year's conference, "Advancing Health Care through Consultation, Technology and Tradition," will provide the most up-to-date and important information Tribal leaders, health directors and consumers will need as they work toward reducing American Indian and Alaska Native health disparities through continued advancement of the Tribal health care system. In addition to an in-depth, special focus on Health Information Technology, the conference also will offer presentations and workshops on Medicare, Medicaid and Health Care Reform;  Health Care Policy & Advocacy; Health Promotion/Disease Prevention;  Youth Health & Public;  Tribal Oral Health and other cross-cutting topics.  
 
For questions and further information about the Native Youth Health Summit and/or the Annual Consumer Conference, please contact NIHB Staff at 202-507-4070 or acc@nihb.org. 
Funding Opportunities

FY 2014 Vision 21 Tribal Community Wellness Centers: Serving Crime Victims' Needs

 

The U.S. Department of Justice (DOJ) Office for Victims of Crime (OVC) will make up to three awards of up to $660,000 each to tribes or tribal nonprofit organizations to develop and implement a victim-centered Community Wellness framework that extends beyond crisis victim assistance to meet the longer-term, complex needs of victims, survivors, and their families. The framework must include a Community Wellness Center that will offer, coordinate, or foster access to a continuum of resources and services that promote victim and community wellness, including a full range of intervention, treatment, health and wellness, prevention, educational and economic development, and cultural resources for the community. Those applying are urged to begin in advance of the
July 15, 2014, deadline.

Form more information, please visit: the Office of Justice Programs website.

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CDC Announces Funding Opportunities for Disease Prevention and Health Promotion

The Centers for Disease Control and Prevention (CDC) is announcing the availability of six new funding opportunity announcements (FOAs) to advance the nation's chronic disease prevention and health promotion efforts.
All six FOAs address one or more of the leading risk factors for the major causes of death and disability in the United States: tobacco use, poor nutrition, and physical inactivity.
A number of the FOAs also address key health system improvements and community supports to help Americans manage their chronic conditions such as high blood pressure and pre-diabetes.
All the FOAs also involve partnerships at the national, state, or local level because public health cannot solve these problems alone. Those currently announced and are posted on www.grants.gov include: 

 

DP14-1417: Partnership to Improve Community Health

DP14-1418: National Implementation and Dissemination for Chronic Disease Prevention

DP14-1419: Racial and Ethnic Approaches to Community Health (REACH)

DP14-1421: A Comprehensive Approach to Good Health and Wellness in Indian Country

DP14-1422: Heart Disease & Stroke Prevention Program and Diabetes Prevention State and Local Public Health Actions to Prevent Obesity, Diabetes, Heart Disease and Stroke

 

Of particular note is DP14-1421PPHF14: A Comprehensive Approach to Good Health and Wellness in Indian Country.
This five-year, $14 million/year initiative aims to prevent heart disease, diabetes, stroke, and associated risk factors in American Indian tribes and Alaska Native villages through a holistic approach to population health and wellness.  The initiative will support implementation of a variety of effective community-chosen and culturally adapted policies, systems, and environmental changes. These changes will aim to reduce commercial tobacco use and exposure, improve nutrition and physical activity, increase support for breastfeeding, increase health literacy, and strengthen team-based care and community-clinical links. 
 
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PH Resources
 
American Journal of Public Health Releases AI/AN Issue 
The June, 2014 edition of the American Journal of Public Health (AJPH) is dedicated to raising awareness and disseminating  research on public health among American Indian and Alaska Native populations.  The edition features 34 articles, commentaries or editorials on public health topics including, but not limited to: pneumonia, suicide prevention, cancer, chronic liver disease, dialysis, heart disease, and substance use.  The journal is available online. 
 
Users can visit the AJPH Website to access the table of contents. Most of the articles are free to access in PDF format.
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New Clinical Guidelines for HIV PrEP


Research results published within the past four years continue to identify new, effective, and accessible HIV prevention strategies - some of which involve re-examining how we utilize HIV medicines designed to halt the virus' progression in the body.  The National Institutes for Health (NIH) and the Centers for Disease Control and Prevention (CDC) have identified Pre-Exposure Prophylaxis (PrEP) as a highly effective prevention strategy and the CDC is currently exploring ways to more widely raise awareness of the potential impact PrEP can have on the epidemic. PrEP is a way for people who do not have HIV but who may be at heightened risk of getting it to prevent HIV infection by taking HIV medicines pill every day.  As there are many intricacies to understanding, accessing, prescribing, and implementing PrEP, the US Public Health Service has issued a new clinical practice guideline for service providers on how to effectively and appropriate implement PrEP with their high risk patients.  
 
 
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2014 NIHB Tribal Public Health Summit RECAP
This year's NIHB 5th Annual Tribal Public Health Summit (TPHS) was a remarkable success! As NIHB's largest TPHS yet, more that 450 Tribal Leaders, Tribal health directors, health care providers, public health professionals, Tribal citizens, and advocates for and friends of AI/AN health and wellness met at the Holiday Inn Grand Montana in Billings, Montana from March 31 - April 2, 2014 for the conference. This year's theme, "Building Healthy Native Communities: "Knowledge, Tools, and Know-How," was a perfect summary of the events that took place to provide educational opportunities for attendees, build connections with federal partners, and support the innovative and noteworthy public health efforts of various Tribal and Native organizations, boards and groups.  
 
More information and plenary presentations are posted on NIHB's website. Please visit our 2014 TPHS webpage! 
Public Health Digest 
A Publication of the National Indian Health Board 
Mission of the National Indian Health Board

One Voice affirming and empowering American Indian and Alaska Native peoples to protect and improve health and reduce health disparities.


This Publication
The National Indian Health Board (NIHB) invites you to learn more about the latest developments in Tribal public health, including updates on NIHB's current projects.  We also invite you to share your news items, comments or questions. 
Utilizing the Advanced Tools of Quality Improvement to Understand the Challenges of Building Healthy Native Communities
Ron Bialek, Laura Sawney-Spencer, John Moran[1]

 

Introduction

When public health professionals are confronted with complex community health or organizational issues or problems, they need to be able to analyze a lot of information quickly and efficiently to make the best possible decisions. The advanced tools of quality improvement (QI)[2],[3] help to synthesize a lot of information, identify the critical areas to focus on, and guide the decision making process.

 

As stated by H. L. Mencken, "For every complex question there is a simple answer and it is usually wrong."[4] The advanced tools of QI are designed to deal with complex issues by guiding those analyzing the issues to focus on hidden interrelationships that are not obvious without detailed analysis and away from simple answers and toward a process of continual refinement of the issue. The best possible decisions require analysis of information; the advanced tools of QI help synthesize and refine information to focus on the critical pieces before developing potential solutions.

 

The advanced tools of QI can be used to help sort through many interrelated strategic possibilities and help narrow them down into the vital few issues on which to focus scarce resources to make the biggest positive impact on the organization and the community. These vital few issues are usually hidden and not apparent when we first start to explore a strategic challenge. However, the advanced tools of QI help a team to focus on the few priorities that will move the organization to its desired future state as quickly as possible.

 

The advanced tools of QI take a systems approach of continuous refinement of the issue, progressing from one tool to the next in a defined application sequence. This is a process of constant refinement to help clarify the issue being investigated and its interrelated components. Figure 1 shows the general approach[5] on how to use the advanced tools of QI in a problem solving sequence to resolve an important issue or problem. When used in sequence, the advanced tools of QI form a dynamic process that helps to continually refine understanding of an issue or problem which narrows the scope and the approach to solve it.


General Approach on How to Use the Advanced Tools of Quality Improvement


Figure 1[6]

 

This is a general flow and does not suit all situations that could arise. When using the advanced tools of QI, a team or individual should think through an approach and then adopt the best sequence of advanced tools of QI to fit the particular situation they are trying to solve.

 

Recent Application

At the 2014 National Tribal Public Health Summit[7], the authors conducted an interactive workshop to demonstrate how two advanced tools of QI can be used to help "Understand the Challenges of Building Healthy Native Communities."

 

The two tools utilized during the workshop were the Affinity Diagram[8] and the Interrelationship Digraph[9]. They were used to demonstrate how to surface issues around the question "What are the Challenges of Building Healthy Native Communities?" and to understand how the various issues that surfaced are related.

 

An Affinity Diagram is a tool for gathering, grouping, organizing, and understanding large amounts of information and helps to identify and draw out common themes from the information which will surface hidden linkages. Affinity diagramming works well with brainstorming to organize a large number of ideas/issues.

 

The process to develop an affinity diagram used for this workshop was as follows:

  1. A broad clear issue statement was developed and posted that focused the group at the macro level. The issue was "What are the Challenges of Building Healthy Native Communities?"
  2. Workshop participants started with individual silent brainstorming and recorded each of their ideas on a Post-It note making sure that each idea was a complete statement.
  3. Then each participant read and randomly placed the ideas on flip chart paper that was posted on the wall. The participants were instructed not to place their ideas in any order since we do not want to suggest any patterns, categories, or headings in advance. They used the whole posting area to randomly post ideas. During this part of the process other participants asked for clarification when an idea was read, but there was no debate, just clarification.
  4. Once all the ideas were posted, the participants engaged in a silent consensus process which included the following: 
    • The entire team gathered around the posted notes
    • There was no talking during this step
    • Individuals looked for ideas that seemed to be related in some way
    • Post-Itnotes that seemed to be related were moved around and placed side by side
    • These steps were repeated until all notes were grouped
    • Note: It was okay to have "loners" that did not seem to fit a group - these were outliers.  It was alright to move a note someone else already moved.  If a note seemed to belong in two groups, it was okay to make a duplicate note and post it in both groups. 
  5. After the ideas were grouped, participants discussed what the grouping patterns showed or uncovered and then developed a heading for each group of ideas. The heading that was placed at the top of a group of ideas had to clearly describe the group and was highlighted in a bright color to distinguish it from the ideas under it. When engaging in this exercise, it is important for headers to be clear and descriptive, and that accurately describe the grouping of ideas they represent. It also is important to take the time to do this step well since it is the foundation for the other tools in the process. An example of affinity diagramming is shown in Figure 2.

The output of the participants' affinity process resulted in the seven header cards shown in Table 1.

 

Table 1

What are the Challenges of Building Healthy Native Communities?

 

 

Once workshop participants agreed on the affinity categories,  an Interrelationship Digraph (ID Graph) was used to help visualize how the various group headings of the issue, "What are the Challenges of Building Healthy Native Communities?" were related and discover any hidden linkages. The process to develop an ID Graph is as follows:

  1. Use the header cards from the affinity diagram and spread them out on a large work surface covered with flip chart paper.
  2. Start with one header card and compare it to all the other header cards. Continue this process until all the header cards have been compared to all the others.
  3. When comparing header cards use an "influence" arrow to connect related header cards.
  4. The arrows should be drawn from the header card that influences to the one influenced. A question to ask when comparing header cards is:
    • Does this card cause any others to happen or is it a result from another card(s). If the answer is "yes" draw a line connecting them. If the answer is "no" do not draw a line connecting them and move on to the next paired comparison.
  5. Then determine the strength of the relationship by assigning a "1" for a weak relationship, a "5" for a medium relationship, and a "10" for a strong relationship.
  6. Use only one-way arrows. The arrow should point toward the effect and away from the cause.
    • Outgoing arrow = basic cause - if solved spillover reaction on a large number of other issues
    • Incoming arrow = secondary issue or bottleneck
  7. Once all the comparisons are completed, count the number of In Arrows, Out Arrows, and the total strength assigned for each header card. An example of one set of comparisons developed by the workshop participants is shown in Figure 3.
  8. The header card with the most outgoing arrows and highest strength will be a driver or root cause. The one with the most incoming arrows and highest strength will be a bottleneck, outcome, or result.
  9. The tabular results of the arrows and strength can be captured on the ID Graph, but as the number of comparisons increase the graph will become messy and difficult to follow. To help with the analysis a matrix summary diagram is employed to show the relationships and strengths among all the header cards as shown in Figure 4. If there are blank sections in the matrix it indicates there was no relationship indicated.

One thing that is not captured in the ID process is the rich conversation that takes place during the development of an ID Graph which is very valuable since people are exposed to a wide variety of knowledge and experience of the other participants to help them in their decision making.

 

Analysis

As shown in Figure 4, the main driver of the header cards was "Native Communities are Resistant to Change" which had the highest strength score and was a driver of all the other categories. There were two main bottlenecks noted: "Limited Access to Health Resources" and "Risk Factors" which had all In arrows. Therefore, as we make improvements to "Native Communities are Resistant to Change" it should drive changes in "Limited Access to Health Resources" and "Risk Factors.

 

Figure 3

 

Figure 4

                                  

The next step in the process, which was not covered in the workshop because of time constraints, is to take the top prioritized header cards and detail them into action steps using a Tree Diagram that provides potential solutions to the header cards. When the Tree Diagram is being constructed on a prioritized issue this is when the team can gather data and evidence to support the interrelationships that were defined to ensure they are valid. This step serves as a check on decisions made about where to focus before developing solutions to the original issue. It is always best to verify and validate with data and evidence whenever possible to ensure the team is making quality decisions.

 

Summary

The output from this exercise was the synthesis of ideas from those who participated in this workshop from many different tribal health departments who brought different concerns, challenges, and perspectives. The participants were able to apply lessons from the presentation to a practical issue that is faced by the public health community. As the participants experimented with the Affinity Diagram, they were able to work with new colleagues in the session and organize their thoughts in logical groups in a manner that allowed the groups to reach consensus. The participants also practiced moving from the Affinity Diagram to the Interrelationship Digraph (ID Graph). In the ID Graph activity, participants were able to see the relationships between the issues identified in the Affinity Diagram on "What are the Challenges of Building Healthy Native Communities?"

 

The process of determining how the identified issues related to one another and the direction of the impact from one issue to the other was somewhat challenging to do in a short period of time. Reaching consensus required additional time. Also, participants struggled with identifying a one-way direction for the arrows from one issue to the next. The exercise was time bound by the workshop's length; other categories could have emerged had there been more time for the process. 

 

We encourage you to try this exercise and the tools with your staff to help your organization understand and develop approaches to the challenges it will face in building healthy Native communities. Please visit the Public Health Foundation webpage for free online resources: 




[1] Ron Bialek, MPP, President, Public Health Foundation (PHF); Laura Sawney-Spencer, MPH, CPH, Supervisor of Public Health Policy & Performance Management, Cherokee Nation Public Health; John Moran, Ph.D., PHF, Senior Quality Advisor.

[2] Management For Quality Improvement: The New QC Tools, S. Mizuno, editor, Productivity Press, 1988

[3] The Public Health Quality Improvement Handbook, R. Bialek, G. Duffy, and J. Moran, editors, ASQ Quality Press, 2009, pp 189 - 213.

[4] BrainyQuote Website,accessed April 30, 2014.

[5] The Public Health Quality Improvement Handbook, R. Bialek, G. Duffy, and J. Moran, editors, ASQ Quality Press, 2009, pp 190.

[6] Acronyms used in Figure 1:  SMART is "Specific, Measureable, Achievable, Relevant, and Time-bound;"   SWOT is "Strengths, Weaknesses, Opportunities, and Threats;" PDPC is "Process Decision Program Chart;" and PERT is "Program Evaluation and Review Technique." 

[7] Fifth Annual National Tribal Public Health Summit, March 31 - April 2, 2014, Billings, Montana.

[8]  The Public Health Quality Improvement Handbook, R. Bialek, G. Duffy, and J. Moran, editors, ASQ Quality Press, 2009, pp 193 - 195.

[9] The Public Health Quality Improvement Handbook, R. Bialek, G. Duffy, and J. Moran, editors, ASQ Quality Press, 2009, pp 199 - 201.

Tribal and Area-wide Response to a Localized Outbreak of Syphilis

Sexually transmitted infections are a well-acknowledged, but under-resourced public health concern.  Sexually transmitted infections historically have disproportionately impacted American Indian and Alaska Native communities, with some Areas seeing rates as high as four times the national average.  Community-level challenges such as aversion to discussing sex, opinions of premarital sex, and cultural taboos compound systems-level challenges such as an overtasked public health workforce, poor access to the latest treatments, updating clinical standing orders to align with new treatment recommendations, accessing new testing technologies, and maintaining a trained clinical and laboratory staff - all of which are common hurdles in American Indian and Alaska Native communities.  Jurisdictional issues arise as well, and make organizing a structured response to any outbreak more complex. 

 

In early November of 2013, a cluster of early syphilis cases was identified in a Tribal community on an Indian reservation community in the Great Plains Indian Health Service Area.  Prior to 2013, syphilis had not been diagnosed within any reservation communities within the area for several decades.  The cases were being identified among young heterosexuals which was particularly concerning as the Great Plains Area generally experiences very high rates of gonorrhea and Chlamydia within its youth populations. Having syphilis introduced into this high risk population could have very damaging consequences, not only for the infected patients, and their partners, but potentially for unborn children of infected patients.  

 

Realizing the gravity of the situation and high potential for rapid spread of this disease within reservation and neighboring communities, plans were laid out for an organized and structured response.  The response included bringing together parties engaged in the active containment of this outbreak to communicate regularly, share resources, and coordinate services - including those engaged in clinical treatment and screening; disease investigation; community outreach, education and screening; and laboratory services.

 

The STD Program Manager of the Great Plains Area Indian Health Service first alerted the Area Chief Medical Officer, Area Medical Epidemiologist, Area Director and all IHS/Tribal/Urban facilities within the Area that syphilis had been identified in the area, and that the potential for transmission was high. 

 

Immediately, service providers were encouraged to increase screening for syphilis for anyone person than 15 years of age who presented for care at their facilities - especially those patients presenting with unusual sores or rashes.  A syphilis clinical review webinar was arranged for health care providers within the entire Great Plains Area, and subsequently repeated on December 16, 2013 to ensure that providers were prepared to diagnosis and treat upon presentation. 

 

Local efforts immediately ramped up to mobilize the community and ensure widespread awareness.  Social media awareness campaign was launched via the Facebook pages of the Great Plains Area, the National Coalition of STD Directors, and the Tribe.  Ads were taken out in the Tribal newspaper, and staff conducted live radio broadcasts to educate the community and promote screening efforts.  Community Health Representatives (CHRs), Tribal health educators, and the public health nursing staff began conducting educational sessions within the districts of the reservations, and holding targeted testing events for community members, schools, and Tribal jails.  All the testing efforts identified additional syphilis cases.

 

State disease investigation specialists (DIS) encountered difficulty early on locating and communicating with people living on the reservation who may have been exposed to syphilis.  Tribal community health representatives (CHRs) volunteered, based upon their familiarity with and knowledge of the community, to partner with the state DIS to conduct investigation on the reservation and assist with partner elicitation and notification.  This proved an invaluable collaboration as funding support to allow the state DIS response teams to spend more time on-site instead of traveling back and forth from their home offices was not available. 

 

Through heightened awareness, glitches pertaining to processing blood specimens through the reference lab were found and corrected.  The Great Plains Area Clinical Applications Coordinator was asked to develop and deploy an electronic Health records reminder which would help prompt clinicians to perform recommended screening.

 

It was determined that as efforts continued to grow and more parties were becoming involved in the coordinated response that a concerted effort to increase regular communication would be required.  The Area STD Program Manager organized a standing weekly call to review the most recent epidemiology, report out on contact management, screening, and community education efforts, and to discuss additional efforts to curb the spread.  Tribal and state health department staff, epidemiologists, DIS, Indian Health Service area and service unit staff, Centers for Disease Control and Prevention (CDC) staff, state American Indian liaisons, CHRs, private clinic staff, Tribal Epidemiology Center staff, and a representative from the National Indian Board were all brought together and were given equal opportunity to address and resolve issues, celebrate success, and share resources.  Everyone heard the same information at the same time and minutes were taken at each session and provided to the attendees following each session.  The calls resulted in the Tribe adopting a Tribal resolution that resulted in a CDC Epi Response Team being sent to the reservation for a week long containment effort that includes intense on-site training for Tribal and IHS staff, field visits with clinical staff, field screening events, and intense outreach.  These Epi Team members are still engaged in the ongoing update calls and support community efforts from their posts in Atlanta. 

 

The combined efforts and inclusion of all stakeholder, couples with resource sharing, honest communication, active problem solving, and the consistent dedication of all parties has made a significant impact.  Within the span of 10 months, the number of new syphilis cases being identified is decreasing, the community response has been positive, and the end is within sight.
Best Practices for Providing Care for Native Transgender Women for Indian Health Service and non-Indian Health Service Care Providers

Michaela Grey, MPH, Matt Ignacio, MSSW, Renae Gray, and Sasha James

 

For many American Indian/Alaska Native communities, the term transgender is new and may be riddled with confusion.  The Center of Excellence for Transgender Health at University of California San Francisco defines the term transgender as "across gender" or "beyond gender"; this is an umbrella, community-based term that applies to people whose behaviors and identities contradict the dominant society's expectations of man and women, including cross dressers (those who wear the clothing of the other sex), gender queer people (those who feel they belong to either both genders or no gender) and transsexuals (those who take hormones and have the gender confirmation surgery).[2]  Although transgender people are often categorized with the lesbian, gay, and bisexual community (i.e. LGBT community), it is important to note the term "transgender" is not a classification of sexual orientation. Furthermore, Native transgender identities may additionally carry a cultural categorization and significance.  It is critical that service providers understand the tenets of transgender identity and the health disparities that exist for transgender people in order to provide appropriate care and services, but also to inform the creation of relevant HIV prevention and treatment strategies. 

 

According to the Centers for Disease Control and Prevention (CDC) Fact Sheet HIV Among Transgender People in the United States, transgender women are at high risk for HIV infection.  In 2010 report comparing HIV infections and gender categories, the highest numbers of new HIV infections were reported among transgender women.[1]  High rates of substance and alcohol use, violence, stigma, discrimination, sex work and incarceration are some factors that all contribute to higher risk for HIV infection.[1]  Specifically, American Indian, Alaska Native and Native Hawaiian (hereafter, 'Native') transgender women also experience culturally-specific challenges such as limited or non-existent access to hormone therapy at Indian Health Service facilities, discrimination from health care providers with limited knowledge of the needs of transgender patients and limited access to transgender-specific HIV prevention messages, particularly in rural/reservation communities. In an effort to prevent the spread of HIV among all Native people, including transgender individuals, it is incumbent for all health care providers and staff to receive more comprehensive gender-identity trainings, administer changes to overall agency protocols inclusive of and to reflect the needs of transgender community members and eliminate any discrimination towards transgender people.

  

Historically, transgender people have held honored roles within Native communities. Transgender people have served as care givers, spiritual leaders, healers, health care providers, and role models (R. Gray, personal communication, March 13, 2014). These roles are critical for the overall health and welfare of Native communities. For many tribes, the experiences of colonization, religious indoctrination, cultural genocide and other historical traumas may have minimized these roles, and in worst-case scenarios, have been lost forever.   Although community knowledge of historical roles may be deficient, Native transgender men and women still exist and may utilize the Indian Health Service to help modify their bodies to affirm their gender. 

  

Indian Health Service (IHS) is an important access point for basic health care for Native people. Native transgender women also access IHS services for primary health care in modifying their bodies to affirm their female gender identity.  In June 2013, the National Pharmacy & Therapeutics Committee (NPTC) released a formulary brief on hormone therapy for those diagnosed with gender dysphoria disorder.[3]  Although the diagnosis gender dysphoria disorder is controversial, as it has negative connotations within the transgender population, the formulary brief provides IHS health care providers treatment guidelines for administering hormones to Native transgender men and women.   The NPTC formulary brief provides recommendations on the usage and monitoring of hormone therapy, and recommends the use of estradiol (female hormone) and spironolactone (testosterone blocker) tablets for the hormone therapy of American Indian and Alaska Native transgender women.[3]

  

Unfortunately, when prescription hormone therapy is not provided by a local, trusted medical provider - in this case IHS, transgender patients may have to acquire hormone medications and related supplies (i.e. sterile syringes) through untrained, unsupervised contacts, often through social networks. The serious threats this poses to one's health may include: medication dispersed by an untrained provider, HIV and other medication drug interactions, over/under medication, unmanaged side effects, overdose and death. Furthermore, if sterile syringes are necessary for hormone injections and there is no access to sterile injection equipment, transgender patients may have no other option but to re-use or share injection equipment, placing them at very high risk for HIV and other blood-borne disease infection (e.g. Hepatitis C).

  

In addition to obtaining hormone prescriptions, Native transgender women experience a number of obstacles when accessing either routine or emergency health care.   Obstacle number one is the legal name assigned to some Native transwomen is incongruent with their gender presentation.  Typically, IHS health clinics use birth names to identify their patients.  For most patients, birth names are congruent with the gender presented, which is not the case for a Native Transwoman.  Sitting in a waiting room and presenting as female while answering to a male birth name makes Native transwomen uncomfortable in health clinic settings (S. James, personal communication, March 13, 2014).  To ally anxieties surrounding this issue, clinic administrators may implement the following: 

  1. Obtain direct feedback from representatives or community leaders from the local Native transgender community when making any agency changes to accurately reflect the needs of the local transgender community
  2. Amend patient demographic and intake forms to allow patient to identify a "Preferred Name"
  3. Train all health care staff to use preferred name identified by patient, use appropriate pronouns (e.g. "she", "him", "her", etc...) associated with preferred name
  4. Amend patient demographic and intake forms to be gender inclusive, including categories for:
    • "Transgender (Male-to-Female)" 3
    • "Transgender (Female-to-Male)" 3
    • "Other" (with a blank line to complete) 3
  5. Ongoing staff education on issues of gender-identity and transgender health needs

Making these changes to patient demographic forms may ease transgender patient's anxiety about entering the clinic for either routine or emergency health care.  These changes will also make it easier for health care providers to identify transgender patients and assess their transition status. Additionally, making these changes is a way to begin restoring and building trust between transgender community members and IHS health care staff, ultimately, improving the overall community health and reducing HIV infection rates.

  

Beyond the front desk, health care providers should be aware of key health issues Native transwomen face.  Beyond hormone therapy, health issues specific to Native transgender women are high rates of substance & alcohol use, survival sex in exchange for money or a home and/or victims of intimate partner violence.  Although these health issues warrant a multi-pronged public health approach, health care providers can serve a pivotal role when interacting with Native transgender women.  According to the Center of Excellence for Transgender Health at University of California San Francisco, health care providers can employ the following tips while treating Native transgender women,

  • Honor the preferred gender identity and use appropriate pronouns (i.e. female preferred name warrant the use of female pronouns [3]
  • Make time for introductions between provider and patient.  Introductions allow time for providers to ask about preferred name, pronouns and transition status (i.e. pre or post gender confirmation surgery) [3]    
  • Respect the gender identity of your transgender patient, which includes treating her body as if it belongs to her.   Transgender women are not defined by their anatomy.  That is, although she presents as female, a Native transgender woman may not have completed the gender confirmation surgery.  Therefore, health care providers must be cognizant that a transgender patients' body may have traits, characteristics or residual elements that do not affirm their preferred gender identity [3]
  • Treat the medical issue at hand.  Transgender patients still require routine health screenings (i.e. cancer preventative screenings, STD screenings, cardiac testing, etc.).  Health care providers still need to administer health exams that encompass breast exams for cancerous or benign nodules and prostate exams for Native transwomen patients [3]
  • During every medical interview, assess sexual history, sexual risk, and HIV status with all transgender patients.  Encourage transgender patients to test for HIV regularly, properly use condoms and other safe practices       
Health care clinics and emergency departments that amend patient demographic forms to accommodate Native transgender patients make it easier for a health care provider to a) identify transgender patients and b) assess her transition status.  By implementing afore mentioned tips as best practices, IHS providers exhibit increasing cultural sensitivity in treating Native transwomen.  Additionally, making these changes is a way to begin restoring and building trust between transgender community members and IHS health care staff, ultimately, improving the overall community health and reducing HIV infection rates.  As a result, Native transgender women may enter IHS health care clinics with less trepidation about encountering culturally insensitive health care staff delivering inadequate treatment plans.  "I would like to enter the clinic and feel welcomed.  The girls [Native transwomen] won't go off the rez to see the doctor for pills [hormone therapy]".
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[1] Centers for Disease Control and Prevention.  (2013).  HIV Among Transgender People in the United States.  Retrieved from http://www.cdc.gov/hiv/pdf/risk_transgender.pdf
[2] Center of Excellence for Transgender Health, University of California San Francisco.  (2011). Primary Care Protocol for Transgender Patient Care.  Retrieved from http://transhealth.ucsf.edu/trans?page=protocol-00-00
 [3] Indian Health Service National Pharmacy & Therapeutics Committee.  (2013).  NPTC Formulary Brief - Gender Dysphoria.  Retrieved from the Indian Health Services Website.
The National Indian Health Board welcomes your input!  If you would like to submit materials for consideration, please contact the NIHB Public Health Department through the Acting Director of Public Health Programs and Policy,  Robert Foley at rfoley@nihb.org or (202)355-5494.

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