In This Issue
Upcoming Events
NIHB Annual Consumer Conference
September 21-24
Washington, DC 
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October 15-16
Seattle, WA
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National HIV Prevention Conference
December 6-9
Atlanta, GA
Trends in Indian Health is a report describing the Indian Health Service and the status of American Indian and Alaska Native health.
Tribal Epidemiology Centers (TECs)
Anchorage, Alaska

Albuquerque, New Mexico

Sacramento, California

Lac du Flambeau, Wisconsin

Phoenix, Arizona

Window Rock, Arizona

Rapid City, South Dakota

Portland, Oregon

Oklahoma City, Oklahoma

Billings, Montana

Nashville, Tennessee

Seattle, Washington
CDC Public Health Practice Stories from the Field

The Centers for Disease Control and Prevention's (CDC) latest addition to its Public Health Practice Stories from the Field describes how pharmacists on the Yakama Nation Reservation in Washington are helping improve the health of patients with diabetes. The pharmacists help patients manage their diabetes and stay current on lab tests and health checks, thus easing the workload of overburdened primary care providers. Patients who are enrolled in the program are more than twice as likely to have their glucose, blood pressure, and cholesterol under control as nonenrolled patients. Read Pharmacists Help Improve Health of Yakama Indians Living with Diabetes to find out how Yakama achieved this success. 

Public Health Practice Stories from the Field is a collection of stories showcasing success and innovation in public health practice by state, Tribal, local, and territorial (STLT) health agencies. The stories are featured on the STLT Gateway, a web portal for STLT health professionals created by CDC's Office for State, Tribal, Local and Territorial Support. You might also be interested in these other stories promoting heart health: Clinic Takes Team Approach to Controlling Hypertension in Ellsworth, Wisconsin, Public Health and Primary Care Partner in South Carolina to Address Cardiovascular Health, Schenectady County Program Lowers Sodium in Menu Items for Seniors, and Sodium Reduction Campaign Encourages Healthy Choices Among Consumers. 
Changes in SDPI for the Next Funding Cycle

A long-standing funding stream for improving the health of Indian Country, the Special Diabetes Program for Indians (SDPI), is entering its 19th year. The program was established by Congress in 1997 to address diabetes in American Indian and Alaska Native (AI/AN) communities and is one of the nation's most comprehensive and effective efforts to combat diabetes.
                                     
Over the course of the legislative and programmatic history of the SDPI, it has undergone changes and restructuring. Until 2006, the program funded Community-Directed grants that implement diabetes-related activities and services based on local needs and priorities. Beginning in 2006, SDPI expanded to include two new temporary initiatives - the Diabetes Prevention Initiative and the Healthy Heart Initiative.
 
After conducting a period of nationwide Tribal Consultation March 19 through April 20, 2015, and meeting with the Tribal Leaders Diabetes Committee (TLDC) in May, the Acting Director of the Indian Health Service (IHS), Mr. Robert McSwain, on June 29, 2015, issued a Dear Tribal Leader Letter and a Dear Urban Indian Organization Leader Letter regarding the decisions made around SDPI fiscal year 2016 funding distribution and formula. Click here to view the Dear Tribal Leader Letter and Click here to read the Dear Urban Indian Organization Leader Letter.  The following will go into effect for the 2016 cycle of SDPI funding:
  • SDPI set-aside funds formerly assigned to the Centers for Disease Control and Prevention's Native Diabetes Wellness Program will now be assigned to the SDPI Community-Directed grant program.
     
  • For fiscal year 2016, the IHS will utilize a new and competing continuation funding opportunity announcement, allowing all federally recognized Tribes to apply for funding.
     
  • No changes have been to the national funding formula.
     
  • More recent data will be used in the funding formula to address changes in AI/AN user population and diabetes prevalence that have occurred over the past decade.
     
  • The SDPI Diabetes Prevention and Healthy Heart Initiative program will be merged into the SDPI Community-Directed grant program - leading to an increase in fund for all Areas and Urban programs.
The new funding opportunity announcement (that includes the above components) was released via the Federal Register the week of August 3rd. The announcement can be found here.  The applications are due on October 7, 2015.  As the SDPI 2016 application process will be competitive, it is essential that all materials are complete and submitted by the due date. 
 
NIHB will continue to provide updates on SDPI as they become available at www.nihb.org/sdpi.

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. 
Evaluating Cultural Components in Programming
Many Tribes have incorporated traditional practice, healing, or medicine into their programs to revitalize healthy communities. They have relied on the words of their elders and healers to determine elements of their history and culture that historically kept their communities healthy. However, when it comes to evaluating these elements, the process can be challenging since traditional practices do not always align to the evaluation frameworks expected by external funders.  How do programs evaluate non-Western practices using West
ern methods of evaluation?
 
Community-based Participatory Research
As previously mentioned, many Tribes have looked to their community and leaders to help find solutions to problems. This is a form of community-based participatory research (CBPR). CBPR is a partnership approach to research that involves community stakeholders, Tribal representatives, evaluators, and project staff in all aspects of the research or evaluation process
so that all parties can contribute expertise and share decision making and ownership. CBPR seeks to engage community members that are affected by the problems to help research, analyze, and develop strategies to resolve said problems. By involving the community, Tribes are able to get a more complete picture of a particular issue from those that are affected-people are more likely to share openly and honestly when you involve community members and relationships and history are more easily understood. A community is more likely to buy in to a program in which they have been actively involved and it is more likely to meet the community's needs.  It is important to engage the community from the very start of a program that incorporates traditional components. The community is an expert on itself-they know what issues they are currently facing and they know possible solutions. They will also know when the solution has truly been resolved. Look to your community to identify the problem, help with program design, and help with evaluation design.
 
Conducting a Participatory Evaluation
There are many methods to collecting data.  Tribes can conduct talking circles, have community meetings, or host a beading gathering. These are all venues that will allow for the collection of qualitative data.  During these gatherings, it is also possible to gather quantitative data (data that deals with measurable numbers) by having sign-in sheets, demographic forms, participation counts, satisfaction surveys, pre- and post- tests on knowledge or attitudes, etc. While these quantitative data methods are more Western in design, they are being implemented in a more traditional setting.  This is an easier way to gather information while still understanding the comfort level of community members.
 
It's important to include the community in not just evaluation design, but the actual evaluation. You can put out a call for volunteers, or you could directly recruit community members to participate. After recruiting community members, train them on how to evaluate. The training should include information on the evaluation process, skills on running meetings (listening, handling conflict, responding appropriately), interviewing (body language, tone of voice, importance of open ended questions), observation, and recording information (non-verbal messages, what conditions were). This is an excellent skills and capacity building opportunity for the community and individuals alike.  

The evaluators can help run and evaluate the gatherings previously mentioned. They can help analyze the information by verbally processing what occurred. Perhaps they noticed some non-verbal communication that you and your team did not. Maybe they were aware of a reason why people didn't show up to a gathering. Remember to share the results of the analysis with the community to ensure that they agree with the conclusions drawn.
 
Including your community from the very beginning of program implementation can greatly impact program's success. It is vital to also evaluate from the beginning of the program. A program may learn that some elements are not working, or are not as effective as they should be. By evaluating throughout the process, a program is ensuring that the lessons learned can strengthen the program.
 
Some sources of evaluation technical assistance that can help to design a more traditional and community-responsive evaluation plan include:

Tribal Public Health Accreditation:
Sault Ste. Marie Tribe of Chippewa Indians

The Background
The Sault Ste. Marie Tribe of Chippewa Indians (SSM) is a federally recognized Tribe in the Upper Peninsula of Michigan.  The total Tribal Membership is over 40,000 members, with 14,331 members living within the 5 unit service area. In total, the service area encompasses 8,500 square miles over seven counties.
The flag of the Sault Ste. Marie Tribe of Chippewa Indians was designed over 40 years ago. Learn more.
Their Health Division provides over 50,000   patient visit per year.  As a self-governance Tribe, the Tribe assumes full funding and control over health programs, services, functions or activities or portions thereof that the Indian Health Service would otherwise provide. 
Self-governance allows SSM flexibility to manage program funds to best fit the needs of their Tribal members.  

The Health Division services include a wide array of clinical health, behavioral health, community health and traditional medicine.   A Community Health Leadership Team was formed in 2008 and consists of Tribal Board members, Health Board members, community members and staff.  The Leadership Team is the body that reviews and advises Health Division staff and Tribal leadership on health-related grants, programs, and broader initiatives such as public health accreditation.  The SSM Tribe's health services have been accredited for years through the Accreditation Association for Ambulatory Health Care, Inc. (AAAHC) and through the Commission on Accreditation of Rehabilitation Facilities (CARF) for behavioral health.  Only recently, has the Tribe started to organize around the relatively new concept of public health accreditation.

The Buzz
The Tribe learned about and heard about public health accreditation from different sources over the course of 5 years.  According the Bonnie Culfa, RN, MSN, Sault Ste. Marie's Health Director, "We began hearing about public health accreditation at regional and national meetings."  Keweenaw Bay Indian Community, another Tribe in the Upper Peninsula of Michigan, was an original test site for early public health accreditation efforts, and presented on their experience at a quarterly Tribal Health Director's meeting that Ms. Culfa attended. Donna Norkoli, a Health Educator for the SSM Tribe, attended a grant meeting between the Michigan Public Health Institute and the Robert Wood Johnson Foundation where public health accreditation was a key agenda item.  She brought the possibility of public health accreditation to the Community Health Leadership Team.  During a CDC Tribal Consultation Meeting, public health accreditation was brought up by CDC staff.  There, the Health Director met a staff member from the National Indian Health Board (NIHB).  NIHB was in the initial planning stages of its Tribal Accreditation Support Initiative (Tribal ASI).  The program publically launched in November, 2014, and offered small competitive awards to Tribes working on public health accreditation.  According to Ms. Culfa, an elected SSM councilwoman and former NIHB Board of Directors Chairperson, Cathy Abramson, "encouraged us to apply for the NIHB grant."



The Decision
With the buzz of public health accreditation all around and in the ears of Community Health staff, the Health Division Director and the Leadership Team, the next step was to make the decision whether to move forward with accreditation or not.  According to the Health Director, the Leadership Team was "already familiar with [healthcare] accreditation" and committed to quality improvement.  Pointing out that AAAHC does not clearly cover public health services, pursuing public health accreditation was a "natural next thing to do."   "When a good idea comes along, we tend to move on it," says Colleen Commons, Health Education Supervisor.  She describes SSM Tribe and the Tribal leadership as being "really progressive" on health and education.  Gaining support for the idea of accreditation was not as much of an issue as "finding the time and having enough people to do the work."  SSM received the Tribal ASI award from NIHB in February, 2015, and as Ms. Culfa describes, "this was where we initially got our feet wet." 
  
The Dive
SSM is currently working on three documents, their community health assessment (CHA), community health improvement plan (CHIP), and strategic plan, otherwise known as the pre-requisites for applying for public health accreditation.  Given other projects starting around the same time and the short 4 month grant period, "we were scrambling at the beginning.  Some of our processes are very slow and take a long time to get rolling," says Culfa.  A new staff member, Tyler LaPlaunt was hired to link several existing recent health assessments and annual Strategic Community Action plans into the CHA and CHIP.  The Michigan Public Health Institute was contracted to guide the division in updating their strategic plan, which was 15 years old.  The accreditation team very much appreciated the commitment of two Health Board members and the Tribal Chairman who participated in the strategic planning meeting.   Ms. Culfa described the strategic planning process as challenging, but rewarding.  "It was beneficial to see my staff in different roles and articulating opinions. Everybody was getting involved and speaking up."
 
Lessons Learned
Although still early on in the public health accreditation process, the SSM accreditation team has some words of advice for other Tribes who may just be beginning the conversation about public health accreditation in their own communities.  First, find the champion.  "Find someone who wants to champion and can get behind the benefits of accreditation," says Culfa, "and then approach leadership."  The level of excitement of that champion is also important.  Having learned the hard way, SSM also recommends forming a steering committee right away.  One invaluable member of their steering committee is their Operations Manager, Joel Lumsden, who has years of experience with coordinating their current AAAHC and CARF accreditation efforts.  Although the standards and measures are different for PHAB, "he sees through an accreditation lens," says Culfa.  Using both existing Tribal and local resources wisely, supporting key people as champions in the process, and making opportunities for leadership participation have all been essential elements of the Sault Ste. Marie Tribe's path to public health accreditation.

NIHB Builds Upon the Success of the Tribal ASI Program
In the winter of 2014, the National Indian Health Board (NIHB) launched a pilot project with the support of the Centers for Disease Control and Prevention (CDC) titled the Tribal Accreditation Support Initiative.  The project was designed to provide Tribes interested in pursuing public health accreditation fiscal support and technical assistance.
 
Public Health accreditation has only been available since 2011 and to date, there are no Tribes who have been accredited through PHAB, although a few are getting close.  With limited resources, few Tribal examples to go by and unique health organizational structures, the first Tribes to move through the accreditation process are essentially creating a path through new terrain and the lessons they have learned will be invaluable to Tribes that will follow.  Through the Tribal ASI, NIHB is committed to elevating Tribal accreditation stories, facilitating the sharing of Tribal examples and resources and supporting overall capacity building in Tribal public health systems. 
 
5 Tribes Complete the First Round 
of Tribal ASI
Five Tribes were awarded Tribal ASI funds from February through June, 2015 and completed public health accreditation activities such as the development of Tribal health department strategic plans and workforce development plans.  Each Tribe highlighted their projects during monthly Tribal Accreditation Learning Community (TALC) webinars, hosted by the (NIHB).  Their presentations can be viewed on the NIHB Tribal ASI webpage here.
 
New Funding Opportunity
NIHB and the CDC are pleased to announce a new funding cycle for the Tribal ASI.  The Tribal ASI will fund 6-10 Tribes at amounts ranging from $5,000 to $10,500 to work in one or more categories related to strengthening the Tribal health department and working towards public health accreditation as defined by the Public Health Accreditation Board.  Completed applications are due to NIHB via email by Monday, August 31, 2015, by 11:59pm Eastern Time. For more information, view the full announcement here.
 
You can also inquire about how to join the TALC webinars and other materials being developed through Tribal ASI, by contacting Program Manager, Karrie Joseph at kjoseph@nihb.org.
 

"Getting Together" to Promote Healthy Relationships

ANTHC's Alaska Native Epidemiology Center (EpiCenter) promotes health by providing health data and educational resources for topics including teen-related domestic and sexual violence. The EpiCenter utilized the concept of a safety card, an evidence-based approach to preventing violence in healthcare settings, and created two cards that address relationships and health. The EpiCenter, in partnership with the State of Alaska, recently launched the "Getting Together" safety card to help teens of any gender recognize domestic and sexual violence and understand issues like consent and what a healthy relationship looks and feels like.
 
The "Getting Together" card, a wallet-sized, fold out card with bright colors, images, and emojis, reflects the feedback and guidance of 113 youth from villages and towns across Alaska and from every major racial group, though 75% of youth providing feedback were Alaska Native or American Indian. The card's panels encourage youth
to ask themselves questions about their relationships and to learn about issues like their rights, consent for intimacy, commercial sexual exploitation, and how to help a friend in need. The card also includes multiple teen-friendly online, text, and hotline resources and encourages teens to think of an adult they trust with whom they can discuss these topics. The primary message to teens is that they are not alone in dealing with these difficult issues.
 
The "We Are Worthy" card, just like "Getting Together," was created bygetting feedback from over 110 girls and women in villages and towns all over Alaska, the vast majority of whom were Alaska Native or American Indian. In addition to healthy and unhealthy relationships, "We Are Worthy" also addresses the health effects of violence, including effects on reproductive health.
 


To order safety cards, click here:  www.anthctoday.org/epicenter/healthyfamilies

Also, if you'd like to modify the cards for your state, Tribe, or community or translate them into another language, contact Laura Avellaneda-Cruz (ldavellanedacruz@anthc.org or (907) 729-2489) to obtain the original files.To obtain posters that you can use to display either card and supplement the prevention and awareness messaging, then contact EpiCenter Community Outreach Specialist, Jaclynne Richards (jkoyoumick@anthc.org, or 907-729-2971). 
Effective Management of HIV/HCV
Co-infection in Indian Country
Michaela Grey, MPH

In addition to increasing HIV infections, Indian Country is facing escalating Hepatitis C virus (HCV) incidence.  Between 2012 and 2013, the number of new HIV infections among American Indians/Alaska Natives (AI/AN) increased by 7.9%.  An estimated 1.2 million people in the U.S. are infected with HIV and more than 2.7 to 3.9 million are infected with HCV.

Of those infected with HIV, an estimated 30% people living with HIV may also be co-infected with HCV.  HIV/HCV co-infection can negatively impact an individual's mental, emotional, physical and spiritual health.   However, by providing accurate health information and working closely with those at risk and service providers we can increase awareness, prevention and services for all AI/AN community members, including those living with HIV and HCV. 

In order to unravel these complicated terms, we need to begin with definitions.  The definition of co-infection is to be infected with two or more different disease-causing organisms.  HCV is a liver disease caused by the Hepatitis C virus.  HCV causes the liver to swell and may cause scar tissue to build up.  HIV is the Human Immunodeficiency Virus, which attacks the immune system.  HIV/HCV co-infection is the most common type of co-infection in people living with HIV.  In fact, HCV is categorized as an HIV-related opportunistic illness.  When people have both HCV and HIV, it can be more difficult for the body to fight both infections.  HIV/HCV co-infection may allow more HCV in the blood and allow earlier onset of liver-related problems.  

The symptoms associated with HCV are very similar to symptoms associated with HIV.  People who get HCV may have no symptoms at all, but for those who do experience symptoms, some of the following may present: extreme fatigue, flu-like symptoms, joint pain, muscle pain, "brain fog," loss of appetite, headaches and liver pain.     

In addition to symptoms, HIV and HCV have very similar blood-blood transmission routes and here are a few examples.  HIV and HCV can be transmitted among individuals sharing used equipment to inject drugs.  Transmission was also documented among individuals who received blood products prior to 1992.  HCV and HIV can be transmitted sexually among men who have sex with other men.  And experts believe these high rates are attributed to weakened immune systems, unprotected anal sex, the presence of sexually transmitted infections and multiple sex partners.  In addition, individuals who received homemade piercings and/or tattoos were documented in HCV transmission.  

Testing for HIV and HCV is available in most areas, so check with your local department of health, Tribal health department, IHS clinic, and/or community-based health promotion program.  The following individuals should get tested for HCV: individuals born between 1945 and 1965, those who have injected drugs at least once in their lifetime, recipients of blood products before July 1992, those living with HIV, and those who have signs or symptoms of liver disease.  There are both traditional and rapid testing options for HCV.  Similar test options exist for HIV, so check with your health care provider on which test is best for you.  A person can easily get tested for both at the same time and receive the results in the same visit.

The good news is that HIV and HCV can be monitored and treated by qualified health care providers.  There are multiple treatment options available for those living with HCV - with the most current regimens shown extremely effective in creating a sustained virologic response (which means the virus is undetectable at follow up visits.  And the new regimens have reduced some of the harmful side-effects of past HCV treatments.  Depending on the type of HCV, your physician will determine the best treatment option.  And for those HIV/HCV co-infected, HIV can be treated effectively.  Although some HIV and HCV medications can be harsh on the liver, a physician will determine which medications to use to effectively treat HIV and HCV. 

For those living with HIV and HCV, here are a few practical tips to follow to ensure appropriate co-infection management: medically monitor HIV and HCV in order to stay healthy, limit or eliminate alcohol consumption and smoking, and maintain health body weight.