Danielle R. Gartner

Objective: We explored how Indigenous food sovereignty promotes sustainable human–environment connections when families work together to reinvigorate Indigenous food systems. Design: We employed an Indigenous modification of Photovoice to follow the principles of Anishinaabe Symbol-Based Reflection, which emphasises creating and describing photographs as symbols for a holistic experience that engages mental, emotional and spiritual well-being. Drawing from community-engagement praxis, we co-developed a codebook and analysed transcripts using ATLAS.ti. Settings: This project emerged from a long-term partnership, Wiba Anung (Early Star), between Indigenous community leaders, the Inter-Tribal Council of Michigan and researchers, focused on reclaiming Indigenous practices and promoting food sovereignty and well-being by co-developing resources for Indigenous families. Participants: Six mothers and grandmothers caring for Anishinaabe children under age five across participated. Their intergenerational and caregiving experiences grounded the project in lived realities. Results: Participants shared 147 photographs, discussing the images in a series of five 2-hour meetings. We present images, captions and quotes from our meetings, which together illustrate the experiences of Indigenous families. Discussions focused on the importance of sharing food knowledge between generations, reclaiming Indigenous cultural practices through food and learning from our more-than-human relations to promote holistic well-being. Conclusions: Participants expressed personal well-being as a reflection of broader community and environmental well-being. Food systems become an effective conduit for promoting healing from colonial trauma and rebalancing all aspects of well-being. This illustrates the importance of integrating the holistic practice of relationality and connectedness when mobilising for change through new food and nutrition programming, particularly for Indigenous communities.

Objective: We investigated the impact of work hours and occupational physical demands on preterm birth (PTB) and explored potential effect modifiers of these associations. Methods: 429 Black women employed during pregnancy self-reported hours worked per week. The Karasek Job Content Questionnaire assessed prenatal occupational physical demands. Log binomial regression models were used to estimate associations, adjust for potential confounders, and investigate effect measure modification by psychosocial factors and racism. Results: Prolonged work hours (>40 hours/week) (aPR = 1.83; 95% CI: 0.85, 3.94) and heavy lifting (aPR = 1.33; 95% CI: 0.88, 2.00) were associated with increased PTB prevalence, but awkward body positions were inversely associated with PTB. Social support modified the physical demands and PTB association. Conclusion: Both occupational exposures and non-occupational factors, such as social support, may be important in the etiology of PTB. Export

One need not look far for an example of epidemiologic research where Indigenous people have either been excluded from analyses or have been aggregated with other racial and ethnic identities as an “Other.” Exclusion and aggregation of Indigenous peoples prevents us from adequately characterizing their health in ways that are useful for collective action. In this commentary we describe 3 distinct, yet related, issues underlying the relationships between statistical power ($\beta $) and structural and ideational power related to the “small sample size” problem for Indigenous peoples: (1) inadequate data procurement and management processes, (2) normative methodological practices, and (3) insufficient scientific communication. In the spirit of disciplinary reflection and self-critique, we identify and review the manifestation of these issues in 1 author’s previously published research. We then discuss and reemphasize important contributing historical and contemporary systems of injustice, and, finally, summarize existing promising research and analytic practices. Given that the tools that address the health of numerically large groups dominate teaching and research spaces, we must move toward a paradigm shift to fully provide equity, justice, and beneficence to Indigenous peoples and other “numerically small” groups.

Background: American Indian and Alaskan Native (AIAN) people experience a disproportionately high incidence of human papillomavirus (HPV)-related cancers and mortality, and these rates vary across geographic regions. To address the unexplained regional differences among AIAN people, we describe regional variations and sociodemographic correlates of HPV-related knowledge and HPV vaccination awareness indicators. Methods: A cross-sectional study was implemented with data for 866 AIAN respondents pooled from eight cycles of the Health Information National Trends Survey. We used χ2 tests to determine whether there were regional differences in the indicators and then used multivariable, modified Poisson regression to explore associations between sociodemographic characteristics and HPV-related knowledge and vaccination awareness measures. Results: Of the 13 indicators, just one demonstrated regional variation. However, we observed a high level of uncertainty regarding HPV and HPV vaccine–related knowledge and experience. We also observed that women were more likely than men to have heard of HPV [adjusted prevalence ratio (aPR), 1.29; 95% confidence interval (CI):1.03–1.63], the HPV vaccine (aPR, 1.59; 95% CI: 1.15–2.22), and to have discussed it with their providers (aPR, 3.69; 95% CI: 1.47–9.28). There were also differences by age, education, and insurance status. Conclusions: High levels of uncertainty and lack of regional variation in indicators suggest that there may be missed opportunities across Indian Country for engagement between health care providers and AIAN in HPV-related conversations. Impact: Efforts toward improving HPV knowledge and vaccination should target all at-risk sexes (and genders), age groups, and education levels. Moreover, AIAN-serving health care providers should be empowered with sufficient understanding, so they are prepared for discussions with at-risk patients.

Indigenous people are often misracialized as other racial or ethnic identities in population health research. This misclassification leads to underestimation of Indigenous-specific mortality and health metrics, and subsequently, inadequate resource allocation. In recognition of this problem, investigators around the world have devised analytic methods to address racial misclassification of Indigenous people. We carried out a scoping review based on searches in PubMed, Web of Science, and the Native Health Database for empirical studies published after 2000 that include Indigenous-specific estimates of health or mortality and that take analytic steps to rectify racial misclassification of Indigenous people. We then considered the weaknesses and strengths of implemented analytic approaches, with a focus on methods used in the US context. To do this, we extracted information from 97 articles and compared the analytic approaches used. The most common approach to address Indigenous misclassification is to use data linkage; other methods include geographic restriction to areas where misclassification is less common, exclusion of some subgroups, imputation, aggregation, and electronic health record abstraction. We identified 4 primary limitations of these approaches: (1) combining data sources that use inconsistent processes and/or sources of race and ethnicity information; (2) conflating race, ethnicity, and nationality; (3) applying insufficient algorithms to bridge, impute, or link race and ethnicity information; and (4) assuming the hyperlocality of Indigenous people. Although there is no perfect solution to the issue of Indigenous misclassification in population-based studies, a review of this literature provided information on promising practices to consider.

Background: Although preventable through screening, cervical cancer incidence and mortality are higher among American Indian and Alaska Native women (AIAN) than White women. The Patient Protection and Affordable Care Act's (ACA) Medicaid expansions may uniquely impact access and use of cervical cancer screening among AIAN women and ultimately alleviate this disparity.Methods: Using Medicaid eligible AIAN (N = 4681) and White (N = 57,661) women aged 18–64 years from the 2010–2020 Behavioral Risk Factor Surveillance System, we implemented difference‐in‐differences regression to estimate the association between the Medicaid expansions and guideline‐adherent cervical cancer screening and health care coverage.Results: The Medicaid expansions were not associated with guideline‐adherent cervical cancer screening (AIAN: −1 percentage point [ppt] [95% confidence interval, CI: −4, 2 ppts]; White: 3 ppts [95% CI: −0, 6 ppts]), but were associated with a 2 ppt increase (95% CI: 0, 4 ppt) in having had a pap test in the last 5 years among White women. The Medicaid expansions were also associated with increases in having a health plan (AIAN: 5 ppts [95% CI: 1, 9]; White: 11 ppts [95% CI: 7, 15]) and decreases in avoiding medical care due to costs (AIAN: −8 ppts [95% CI: −13, −2]; White: −6 ppts [95% CI: −9, −4]).Conclusions: While we observed improvements in health care coverage, we did not observe changes to guideline‐adherent cervical cancer screening following the ACA's Medicaid expansions. Given the disproportionate burden of cervical cancer among AIAN women, identifying ways to improve cervical cancer screening uptake and delivery should be prioritized to reduce preventable deaths.

Objective: To explore population‐level American Indian & Alaska Native‐White inequalities in cesarean birth incidence after accounting for differences in cesarean indication, age, and other individual‐level risk factors.Data Sources and Study Setting: We used birth certificate data inclusive of all live births within the United States between January 1 and December 31, 2017.Study Design: We calculated propensity score weights that simultaneously incorporate age, cesarean indication, and clinical and obstetric risk factors to estimate the American Indian and Alaska Native‐White inequality.Data Collection/Extraction Methods: Births to individuals identified as American Indian, Alaska Native, or White, and residing in one of the 50 US states or the District of Columbia were included. Births were excluded if missing maternal race/ethnicity or any other covariate.Principal Findings: After weighing the American Indian and Alaska Native obstetric population to be comparable to the distribution of cesarean indication, age, and clinical and obstetric risk factors of the White population, the cesarean incidence among American Indian and Alaska Natives increased to 33.4% (95% CI: 32.0–34.8), 3.2 percentage points (95% CI: 1.8–4.7) higher than the observed White incidence. After adjustment, cesarean birth incidence remained higher and increased in magnitude among American Indian and Alaska Natives in Robson groups 1 (low risk, primary), 6 (nulliparous, breech presentation), and 9 (transverse/oblique lie).Conclusions: The unadjusted lower cesarean birth incidence observed among American Indian and Alaska Native individuals compared to White individuals may be related to their younger mean age at birth. After adjusting for this demographic difference, we demonstrate that American Indian and Alaska Native individuals undergo cesarean birth more frequently than White individuals with similar risk profiles, particularly within the low‐risk Robson group 1 and those with non‐cephalic presentations (Robson groups 6 and 9). Racism and bias in clinical decision making, structural racism, colonialism, or other unidentified factors may contribute to this inequality.