15th International Congress on Circumpolar Health

2013 vol. 72, supplement 1

Proceedings of the

15th International Congress on Circumpolar Health

August 5–10, 2012, Fairbanks, Alaska, USA

Edited by Neil Murphy and Alan Parkinson

International Journal of Circumpolar Health (www.circumpolarhealthjournal.net) International Journal of Circumpolar Health (IJCH) is published by Co-Action Publishing on behalf of the Circumpolar Health Research Network, an organization based in Canada and registered under the Northwest Territories Societies Act. The journal was established in 1972 and became an open access journal at the beginning of 2012 at which time print subscription sales also ceased. IJCH specializes in Arctic and Antarctic health issues. It provides a forum for many disciplines, including the biomedical sciences, social sciences, and humanities as they relate to human health in high latitude environments. The journal has a particular interest in the health of indigenous peoples. IJCH welcomes Research papers, Review articles, Short communications, Circumpolar Voices, Book reviews, PhD summaries, and Letters to the Editor. EDITORIAL TEAM Editor-in-Chief Kue Young, Dalla Lana School of Public Health, University of Toronto, Canada Scientific Editors David L. Driscoll, University of Alaska, United States Marit Jørgensen, Steno Diabetes Centre, Denmark Juhani Leppäluoto, University of Oulu, Finland Jon Øyvind Odland, University of Tromsø, Norway Pamela Orr, University of Manitoba, Canada PUBLICATION INFORMATION International Journal of Circumpolar Health, eISSN 2242-3982, is an Open Access journal and applies the Creative Commons Attribution 3.0 Unported (CC BY 3.0) License. Under this license, copyright is retained by the author who grants to users the right to download, reuse, reprint, modify, distribute and copy articles for any non-commercial purpose as long as the original author(s) and source are properly cited. No permission is required from the publishers or author(s). All articles are posted online immediately as they are ready for publication and are assigned a DOI number (Digital Object Identifier) whereby they become searchable and citable without delay. International Journal of Circumpolar Health full text articles are accessible via the journal’s website at www.circumpolarhealthjournal.net as well as via international search engines such as Google and Google Scholar. International Journal of Circumpolar Health is indexed/tracked/covered by: Directory of Open Access Journals (DOAJ), EBSCOhost (2007-), Reactions Weekly, Embase, Index Copernicus, MEDLINE, ProQuest Health and Medical Complete, ProQuest Medical Library, PubMed, PubMed Central, Science Citation Index, Social Sciences Citation Index, Scopus (1997-), Swets Information Services+ To submit manuscripts and for information about publication fees, see www.circumpolarhealthjournal.net. For information on reprints, advertisements and other commercial sales, please contact [email protected] Typeset by Datapage (India) Private Ltd, Chennai, India Printed by Hobbs the Printers Ltd, Hampshire, United Kingdom

Proceedings of the 15th International Congress on Circumpolar Health

Circumpolar Health Comes Full Circle

August 5 10, 2012, Fairbanks, Alaska, USA

Editors:

Neil Murphy and Alan Parkinson

CONGRESS STEERING COMMITTEE ICCH15 Steering Committee Members Michael Bruce Chair, Aug 2009 to June, 2012 [email protected]

Laura Banfield Student Committee [email protected]

Rhonda Johnson Chair, June- Aug, 2012 [email protected]

Jennifer Jones Student Committee [email protected]

Kimberly Rogers Continuing Education Credits [email protected]

Alan Parkinson Affiliated Meetings [email protected]

Anne Lanier [email protected]

Tammy Zulz Finance, Aug 2009 to June, 2012 [email protected]

James Berner [email protected]

Ted Mala [email protected]

Jay Butler [email protected]

Sarah McConnell [email protected]

Louisa Castrodale [email protected]

Joe McLaughlin [email protected]

George Conway [email protected]

Karen Miernyk [email protected]

Denise Dillard [email protected]

Ellen Provost [email protected]

David Driscoll [email protected]

Diana Redwood [email protected]

Robert Furilla [email protected]

Caroline Renner [email protected]

Donna Galbreath [email protected]

Barbara Taylor [email protected]

Craig Gerlach [email protected]

Barbara Williams [email protected]

AbbieWilleto Wolfe Finance, June to Aug, 2012 [email protected] Larry Duffy Local Organizing Committee [email protected] Mary Van Muelken Local Organizing Committee [email protected] Neil Murphy Publications [email protected] Thomas Hennessy Scientific Program [email protected] Jay Wenger Scientific Program, until Sep 2011 [email protected]

Carl Hild [email protected] Vanessa Hiratsuka [email protected] Michael Klatt [email protected]

Local Fairbanks Organizing Committee Members Co-Chairs: Jacoline Bergstrom & Lawrence Duffy

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Committee Members: Sven Ebbesson, Craig Gerlach Anna Godduhn Victor Joseph Sarah McConnell Tim Murphrey

Mark Miller Cyndi Nation Greg Owens Helen Renfrew Mary van Muelken Carla Willetto Denise Wartes

Circumpolar Health Supplements 2013

Committees

Scientific Program Committee Leif Albertson [email protected]

Larry Duffy [email protected]

Gert Mulvad [email protected]

Paul Anderson [email protected]

Sven Ebbesson [email protected]

Nancy Nix [email protected]

Laura Arbor [email protected]

Tricia Franklin [email protected]

Alan Parkinson [email protected]

Andrea Bersamin [email protected]

Thomas Hennessy [email protected]

Richard Brown [email protected]

Rhonda Johnson [email protected]

Michael Bruce [email protected]

Janet Johnston [email protected]

Dana Bruden [email protected]

Janet Kelly [email protected]

Lisa Bulkow [email protected]

Melissa Kemberling [email protected]

Abel Bult-Ito [email protected]

Michael Klatt [email protected]

Jay Butler [email protected] Candice Lys [email protected] Sally Carraher [email protected] Susan Chatwood [email protected] George Conway [email protected] Melanie Cueva [email protected] Denise Dillard [email protected] David Driscoll [email protected]


Anders Koch [email protected] Jennifer Lincoln [email protected] Stephen Livingston [email protected] Ted Mala TMala@SouthcentralFoundation. com

Ellen Provost [email protected] Greg Raczniak [email protected] Karen Rudolph [email protected] Brenna Simons [email protected] Rosalyn Singleton [email protected] Tenaya Sunbury [email protected] Barbara Taylor [email protected] Timothy Thomas [email protected] Mikhail Voevoda [email protected] Sophia Wadowska [email protected] Barbara Williams [email protected]

Joe McLaughlin [email protected]

AbbieWilletto Wolfe [email protected]

Brian McMahon [email protected]

Tammy Zulz [email protected]

Karen Miernyk [email protected]

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Committees

ICCH15 International Scientific Advisory Group

TiinaIka¨heimo [email protected]

Susan Chatwood [email protected]

Rhonda Johnson [email protected]

Sven Hassler [email protected]

Candice Lys [email protected]

Michael G. Bruce [email protected]

Preben Homøe [email protected]

Michael Voevoda [email protected]

Jay Wenger [email protected]

GertMulvad [email protected]

Valery Manchuk [email protected]

Photo Credits: Don R. Bertolette Greg Martin Photography James M. Murphy Riverboat Discovery Inc.

Visions Meeting and Event Management Karen Zak General Manager Tina Day Director Lorell David Meeting Planner Susie Miller Meeting Planner Brooke Ivy Meeting Planner Jenn Gifford Technology & Admin Support Supervisor Sara Foss Meeting Planning Support

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ICCH15 Publication Committee Senior Editors Neil Murphy Alan Parkinson

Behavioral Health: Chronic Disease: Health Services: Healthy Communities: Healthy Families: Infectious Disease: Nutrition: Research in the North:

Associate Editor Vanessa Hiratsuka Meera Narayanan Rhonda Johnson Mike Brubaker Anne George Tom Hennessey Phil Loring Tim Thomas

Assistant Editor Burhan Khan Cindy Schraer, Anne Lanier Bree Kessler Danita Koehler Julia Smith Sandra Romain

Russian Liaison / Associate Editor Marina Dent Administration Barbara Williams


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TABLE

OF

CONTENTS

Forewords Dedication to the memory of Professor Leonid Sevastyanovich Polikarpov . . The ugly ducklings that became swans . . . . . . . . . . . . . . . . . . . . . . . . . . . . Neil J. Murphy Message from the President of the American Society of Circumpolar Health . Rhonda M. Johnson ‘‘On Completing the Circle and the Human Health Legacy of the International Polar Year’’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alan Parkinson

. . . . . . . . . 16 . . . . . . . . . 18 . . . . . . . . . 20

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Awards John Arthur Hildes Circumpolar Health Awards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Jens Peder Hart Hansen Fellow Awards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Special Addresses Keynote Presenters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Featured Topic Presenters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Chapter 1. Plenary Sessions Papers The roundtrip to Fairbanks: the circumpolar health movement comes full circle, part II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Neil J. Murphy Presentation Synopses Circumpolar health what is next? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Kue Young Childhood exposure to domestic violence: implications and opportunities for circumpolar health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Linda Chamberlain Developing healthy communities: understanding maternal child health determinants in Nunavut . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Laura Arbour Arctic health and research: challenges and opportunities . . . . . . . . . . . . . . . . . . . 56 Fran Ulmer Vulnerable populations: health of humans and animals in a changed landscape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Birgitta Evenga˚rd Common problems, uncommon solutions in the Arctic. . . . . . . . . . . . . . . . . . . . . 61 Mead Treadwell 6


Chapter 2. Featured Presentations Featured Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Papers The Arctic human health initiative: a legacy of the International Polar Year 20072009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Alan J. Parkinson Rebuilding northern foodsheds, sustainable food systems, community well-being, and food security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 S. Craig Gerlach, Philip A. Loring Perceptions of needs regarding FASD across the province of British Columbia, Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Anne George, Cindy Hardy, Erica Clark The Nuka System of Care: improving health through ownership and relationships 93 Katherine Gottlieb Lots to lose: reversing the obesity epidemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Ward B. Hurlburt HPV vaccines for circumpolar health: summary of plenary session, ‘‘Opportunities for Prevention: Global HPV Vaccine’’ and ‘‘Human Papillomavirus Prevention: The Nordic Experience’’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101 Eileen F. Dunne, Anders Koch Presentation Synopses Native voices: native peoples’ concepts of health and illness . . . . . . . . . . . . . . . . .106 Donald A.B. Lindberg An Alaska Native leader’s views on health research . . . . . . . . . . . . . . . . . . . . . . .108 H. Sally Smith Northern leaders perspective on Arctic development . . . . . . . . . . . . . . . . . . . . . .113 Patricia A.L. Cochran

Chapter 3. Behavioral Health Evolution of behavioral health issues in the circumpolar north in the 45 years of the ICCH * Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133 Vanessa Hiratsuka Papers Survey of northern informal and formal mental health practitioners . . . . . . . . . . .135 Linda O’Neill, Serena George, Stefanie Sebok Traditional living and cultural ways as protective factors against suicide: perceptions of Alaska Native university students. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .142 Christopher R. DeCou, Monica C. Skewes, Ellen D.S. Lo´pez Prenatal alcohol exposure among Alaska Native/American Indian infants . . . . . . .147 Burhan A. Khan, Renee F. Robinson, Julia J. Smith, Denise A. Dillard Distance education for tobacco reduction with Inuit frontline health workers . . . . .153 Rob Collins, Merryl Hammond, Catherine L. Carry, Dianne Kinnon, Joan Killulark, Janet Nevala Circumpolar Health Supplements 2013

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Associations of deliberate self-harm with loneliness, self-rated health and life satisfaction in adolescence: Northern Finland Birth Cohort 1986 Study . . . . . . . . . . . . . . . . .162 Anna Reetta Ro¨nka¨, Anja Taanila, Markku Koiranen, Vappu Sunnari, Arja Rautio An examination of the social determinants of health as factors related to health, healing and prevention of foetal alcohol spectrum disorder in a northern context the brightening our home fires project, Northwest Territories, Canada. . . . . . . . . .169 Dorothy Badry, Aileen Wight Felske Smoking-related knowledge, attitudes, and behaviors among Alaska Native people: a population-based study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .175 Kristen Rohde, Myde Boles, Chris J. Bushore, Barbara A. Pizacani, Julie E. Maher, Erin Peterson Attitudes toward harm reduction and abstinence-only approaches to alcohol misuse among Alaskan college students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .182 Monica C. Skewes, Vivian M. Gonzalez Informal and formal mental health: preliminary qualitative findings . . . . . . . . . . .187 Linda O’Neill, Serena George, Corinne Koehn, Blythe Shepard Energy drink use, problem drinking and drinking motives in a diverse sample of Alaskan college students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .194 Monica C. Skewes, Christopher R. Decou, Vivian M. Gonzalez Resituating the ethical gaze: government morality and the local worlds of impoverished Indigenous women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .200 Caroline L. Tait Discovering unique tobacco use patterns among Alaska Native people . . . . . . . . .206 Julia A. Dilley, Erin Peterson, Vanessa Y. Hiratsuka, Kristen Rohde Intimate partner violence in the Canadian territorial north: perspectives from a literature review and a media watch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .215 Pertice Moffitt, Heather Fikowski, Marshirette Mauricio, Anne Mackenzie Tobacco use prevalence disentangling associations between Alaska Native race, low socio-economic status and rural disparities . . . . . . . . . . . . . . . . . . . . . . . . . . . . .222 Julia A. Dilley, Erin Peterson, Matthew Bobo, Kathryn E. Pickle, Kristen Rohde ‘‘I only smoke when I have nothing to do’’: a qualitative study on how smoking is part of everyday life in a Greenlandic village . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .231 Anne Birgitte Jensen, Lise Hounsgaard High prevalence of medicine-induced attempted suicides among females in Nuuk, Greenland, 20082009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .237 Lars Heymann Bloch, Gitte Hansen Drachmann, Michael Lynge Pedersen Extended Abstracts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .241 Conference Abstracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .258

Chapter 4. Chronic Disease Chronic disease * Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .269 Meera Narayanan Papers Bridging storytelling traditions with digital technology . . . . . . . . . . . . . . . . . . . . .270 Melany Cueva, Regina Kuhnley, Laura J. Revels, Katie Cueva, Mark Dignan, Anne P. Lanier 8


Experience with cochlear implants in Greenlanders with profound hearing loss living in Greenland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .276 Preben Homøe, Ture Andersen, Aksel Grøntved, Lone Percy-Smith, Michael Bille Raised BMI cut-off for overweight in Greenland Inuit a review . . . . . . . . . . . . .279 Stig Andersen, Karsten Fleischer Rex, Paneeraq Noahsen, Hans Christian Florian Sørensen, Gert Mulvad, Peter Laurberg Cystatin C and lactoferrin concentrations in biological fluids as possible prognostic factors in eye tumor development. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .284 Mariya A. Dikovskaya, Alexandr N. Trunov, Valeriy V. Chernykh, Tatyana A. Korolenko HPV genotypes detected in cervical cancers from Alaska Native women, 19802007 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .289 Janet J. Kelly, Elizabeth R. Unger, Eileen F. Dunne, Neil J. Murphy, James Tiesinga, Kathy R. Koller, Amy Swango-Wilson, Dino Philemonof, Xay Lounmala, Lauri E. Markowitz, Martin Steinau, Thomas Hennessy Preliminary analysis of immune activation in early onset type 2 diabetes . . . . . . . .293 IJulia D. Rempel, Juliet Packiasamy, Heather J. Dean, Jonathon McGavock, Alyssa Janke, Mark Collister, Brandy Wicklow, Elizabeth A.C. Sellers The peculiarities of food allergies in accordance with the level of injury of respiratory tract in children of Eastern Siberia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .301 Irina V. Borisova, Svetlana V. Smirnova The influence of social support on risk of acute cardiovascular diseases in female population aged 2564 in Russia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .305 Valery V. Gafarov, Dmitry O. Panov, Elena A. Gromova, Igor V. Gagulin, Almira V. Gafarova Evaluation of serum procathepsin B, cystatin B and cystatin C as possible biomarkers of ovarian cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .309 Elena A. Gashenko, Valentina A. Lebedeva, Ivan V. Brak, Elena A. Tsykalenko, Galina V. Vinokurova, Tatyana A. Korolenko Comparative analysis of clinical, electrocardiographic, angiographic and echocardiographic data of indigenous and non-indigenous residents of Yakutia with coronary artery atherosclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . .314 Natalya Vladimirovna Makharova, Michael Ivanovich Voevoda, Faina Fedorovna Lyutova, Irina Andreevna Pinigina, Vera Evstafievna Tarasova The ethnic differences of stroke in Yakutia . . . . . . . . . . . . . . . . . . . . . . . . . . . . .321 Sargylana A. Chugunova, Tatiana Ya. Nikolaeva The influence of depression on risk development of acute cardiovascular diseases in the female population aged 2564 in Russia. . . . . . . . . . . . . . . . . . . . . . . . . . .325 Valery V. Gafarov, Dmitry O. Panov, Elena A. Gromova, Igor V. Gagulin, Almira V. Gafarova Extended Abstracts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .330 Conference Abstracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .342 Circumpolar Health Supplements 2013

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Chapter 5. Health Services Health Services * Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .359 Rhonda M. Johnson Papers Tribal implementation of a patient-centred medical home model in Alaska accompanied by decreased hospital use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .361 Janet M. Johnston, Julia J. Smith, Vanessa Y. Hiratsuka, Denise A. Dillard, Quenna N. Szafran, David L. Driscoll The nature of nursing practice in rural and remote areas of Greenland . . . . . . . . .368 Lise Hounsgaard, Anne Birgitte Jensen, Julie Præst Wilche, Ilone Dolmer Alaska Dental Health Aide Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .376 Sarah Shoffstall-Cone, Mary Williard The use of remote presence for health care delivery in a northern Inuit community: a feasibility study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .381 Ivar Mendez, Michael Jong, Debra Keays-White, Gail Turner Extended Abstracts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .389 Conference Abstracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .397

Chapter 6. Healthy Communities Community health in a time of change * Introduction . . . . . . . . . . . . . . . . . . . . . . . . .407 Michael Y. Brubaker Papers Disseminating research in rural Yup’ik communities: challenges and ethical considerations in moving from discovery to intervention development . . . . . . . . . .409 Inna Rivkin, Joseph Trimble, Ellen D.S. Lopez, Samuel Johnson, Eliza Orr, James Allen The polar bear in the room: diseases of poverty in the Arctic . . . . . . . . . . . . . . . .417 Chris Nelson Animal source food intake and association with blood cholesterol, glycerophospholipids and sphingolipids in a northern Swedish population . . . . . . . . . . . . . . . . . . . . . .421 Wilmar Igl, Afaf Kamal-Eldin, A˚sa Johansson, Gerhard Liebisch, Carsten Gnewuch, Gerd Schmitz, Ulf Gyllensten ‘‘What makes life good?’’ Developing a culturally grounded quality of life measure for Alaska Native college students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .428 Dinghy Kristine B. Sharma, Ellen D.S. Lopez, Deborah Mekiana, Alaina Ctibor, Charlene Church Improving the state of health hardware in Australian Indigenous housing: building more houses is not the only answer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .435 Paul Pholeros, Tess Lea, Stephan Rainow, Tim Sowerbutts, Paul J. Torzillo The RISC research project: injury in First Nations communities in British Columbia, Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .441 M. Anne George, Rod McCormick, Chris E. Lalonde, Andrew Jin, Marianna Brussoni 10


Effects of increase in temperature and open water on transmigration and access to health care by the Nenets reindeer herders in northern Russia. . . . . . . . . . . . . . . .447 Philippe Amstislavski, Leonid Zubov, Herman Chen, Pietro Ceccato, Jean-Francois Pekel, Jeremy Weedon Risk communication and trust in decision-maker action: a case study of the Giant Mine Remediation Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .456 Cynthia G. Jardine, Laura Banfield, S. Michelle Driedger, Christopher M. Furgal Mortality trends among Alaska Native people: successes and challenges . . . . . . . .463 Peter Holck, Gretchen Ehrsam Day, Ellen Provost Abusive head trauma among children in Alaska: a population-based assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .472 Jared Parrish, Cathy Baldwin-Johnson, Margaret Volz, Yvonne Goldsmith Washeteria closures, infectious disease and community health in rural Alaska: a review of clinical data in Kivalina, Alaska . . . . . . . . . . . . . . . . . . . . . . . . . . . .480 Timothy K. Thomas, Jake Bell, Dana Bruden, Millie Hawley, Michael Brubaker Prevalence and sensitization of atopic allergy and coeliac disease in the Northern Sweden Population Health Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . .484 Stefan Enroth, Ingrid Dahlbom, Tony Hansson, A˚sa Johansson, Ulf Gyllensten Renewable energy and sustainable communities: Alaska’s wind generator experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .491 Richard Steven Konkel The State of Alaska’s early experience with institutionalization of health impact assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .499 Paul J. Anderson, Sarah Yoder, Ed Fogels, Gary Krieger, Joseph McLaughlin Extended Abstracts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .504 Conference Abstracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .515

Chapter 7. Healthy Families Healthy Families * Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .531 M. Anne George Papers Pathway to Hope: an indigenous approach to healing child sexual abuse . . . . . . . .534 Diane Payne, Kimber Olson, Jared W. Parrish Women’s perspectives on illness when being screened for cervical cancer . . . . . . . .541 Lise Hounsgaard, Mikaela Augustussen, Helle Møller, Stephen K. Bradley, Suzanne Møller Prevalence of postpartum depression in Nuuk, Greenland a cross-sectional study using Edinburgh Postnatal Depression Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . .548 Iben Motzfeldt, Sabina Andreasen, Amalia Lynge Pedersen, Michael Lynge Pedersen Immunological parameters and gene polymorphisms (C-590T IL4, C-597A IL10) in severe bronchial asthma in children from the Krasnoyarsk region, West Siberia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .554 Marina V. Smolnikova, Svetlana V. Smirnova, Maxim B. Freidin, Olga S. Tyutina Circumpolar Health Supplements 2013

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Health status of Native people living in the Republic of Sakha (Yakutia). . . . . . . .561 Tatiana Burtseva, Tatiana Uvarova, Maya Savvina, Viktor Shadrin, Sergei Avrusin, Vyacheslav Chasnyk Prevalence and risk factors of caregiver reported Severe Early Childhood Caries in Manitoba First Nations children: results from the RHS Phase 2 (20082010) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .565 Robert J. Schroth, Shelley Halchuk, Leona Star The future of successful aging in Alaska . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .575 Jordan Lewis What is important in the surroundings in order to extend the healthy life period? A regional study of 19 older women in a northern part of Norway . . . . . . . . . . . .580 Gunn-Tove Minde, Torill M. Sæterstrand Arctic passages: liminality, In˜upiat Eskimo mothers and NW Alaska communities in transition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .585 Lisa Llewellyn Schwarzburg Extended Abstracts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .594 Conference Abstracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .601

Chapter 8. Infectious Disease Infectious Disease * Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .609 Thomas W. Hennessy, Sandra Romain Papers Molecular epidemiology of serotype 19A Streptococcus pneumoniae among invasive isolates from Alaska, 19862010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .611 Karen Rudolph, M.G. Bruce, L. Bulkow, T. Zulz, A. Reasonover, M. Harker-Jones, D. Hurlburt, T.W. Hennessy No evidence of increasing Haemophilus influenzae non-b infection in Australian Aboriginal children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .618 Robert I. Menzies, Peter Markey, Rowena Boyd, Ann P. Koehler, Peter B. McIntyre Increasing trend in the rate of infectious disease hospitalisations among Alaska Native people . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .624 Robert C. Holman, Thomas W. Hennessy, Dana L. Haberling, Laura S. Callinan, Rosalyn J. Singleton, John T. Redd, Claudia A. Steiner, Michael G. Bruce Reducing Alaska Native paediatric oral health disparities: a systematic review of oral health interventions and a case study on multilevel strategies to reduce sugar-sweetened beverage intake. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .633 Donald L. Chi The epidemiology of invasive disease due to Haemophilus influenzae serotype a in the Canadian North from 2000 to 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .646 Jenny L. Rotondo, Lindsey Sherrard, Melissa Helferty, Raymond Tsang, Shalini Desai Helicobacter pylori incidence and re-infection in the Aklavik H. pylori Project . . . .651 Sally Carraher, Hsiu-Ju Chang, Rachel Munday, Karen J. Goodman, the CANHelp Working Group 12


The cost of lower respiratory tract infections hospital admissions in the Canadian Arctic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .658 Anna Banerji, Val Panzov, Joan Robinson, Michael Young, Kaspar Ng, Muhammad Mamdani The epidemiology of invasive pneumococcal disease in the Canadian North from 1999 to 2010. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .666 Melissa Helferty, Jenny L. Rotondo, Irene Martin, Shalini Desai Chlamydia screening practices among physicians and community nurses in Yukon, Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .672 Karolina Machalek, Brendan E. Hanley, Joy N. Kajiwara, Paula E. Pasquali, Cathy J. Stannard Extended Abstracts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .683 Conference Abstracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .745

Chapter 9. Nutrition Making progress on food and nutritional security in the circumpolar north * Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .757 Philip A. Loring Papers Linkages between human health and ocean health: a participatory climate change vulnerability assessment for marine mammal harvesters. . . . . . . . . . . . . . .759 Lily Gadamus Dietary intake of vitamin D in a northern Canadian Dene´ First Nation community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .766 Joyce Slater, Linda Larcombe, Chris Green, Caroline Slivinski, Matthew Singer, Lizette Denechezhe, Chris Whaley, Peter Nickerson, Pamela Orr Adverse health effects of experiencing food insecurity among Greenlandic school children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .774 Birgit Niclasen, Max Petzold, Christina W. Schnohr Culturally tailored postsecondary nutrition and health education curricula for indigenous populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .781 Sarah McConnell Addressing historic environmental exposures along the Alaska Highway . . . . . . . .787 Anna Godduhn, The Northway Health Study Team, Lawrence Duffy The antioxidant level of Alaska’s wild berries: high, higher and highest . . . . . . . . .796 Roxie Rodgers Dinstel, Julie Cascio, Sonja Koukel Collaborating toward improving food security in Nunavut . . . . . . . . . . . . . . . . . .803 Jennifer Wakegijig, Geraldine Osborne, Sara Statham, Michelle Doucette Issaluk Animistic pragmatism and native ways of knowing: adaptive strategies for overcoming the struggle for food in the sub-Arctic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .811 Raymond Anthony Vitamin D status in Greenland * dermal and dietary donations. . . . . . . . . . . . . .818 Stig Andersen, Anna Jakobsen, Hanne Lynge Rex, Folmer Lyngaard, Inge-Lise Kleist, Peder Kern, Peter Laurberg Circumpolar Health Supplements 2013

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Dietary intakes of energy and macronutrients by lactating women of different ethnic groups living in Yakutia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .824 Tatiana Burtseva, Irina Solodkova, Maya Savvina, Galina Dranaeva, Victor Shadrin, Sergei Avrusin, Elena Sinelnikova, Vyacheslav Chasnyk Extended Abstracts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .829 Conference Abstracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .839

Chapter 10. Research in the North Research in the North * Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .849 Timothy Thomas Papers Migration of persons between households in rural Alaska: considerations for study design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .851 Dana Bruden, Michael G. Bruce, Jay D. Wenger, Debby A. Hurlburt, Lisa R. Bulkow, Thomas W. Hennessy Consultation and remediation in the north: meeting international commitments to safeguard health and well-being . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .857 Laura Banfield, Cynthia (Cindy) G. Jardine Challenges in conducting community-driven research created by differing ways of talking and thinking about science: a researcher’s perspective. . . . . . . . . . . . . . . . . . . . . .864 Amy Colquhoun, Janis Geary, Karen J. Goodman Health aspects of Arctic exploration Alaska’s medical history based on the research files of Dr. Robert Fortuine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .871 Kathy Murray ‘‘Double culturedness’’: the ‘‘capital’’ of Inuit nurses . . . . . . . . . . . . . . . . . . . . . .876 Helle Møller Doing the right thing! A model for building a successful hospital-based ethics committee in Nunavut. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .883 Madeleine Cole, Gwen Healey Characteristics of the Frontier Extended Stay Clinic: a new facility model . . . . . . .888 Rosyland Frazier, Sanna Doucette Adapting online learning for Canada’s Northern public health workforce. . . . . . . .895 Marnie Bell, Karen MacDougall Navigating the cultural geography of indigenous peoples’ attitude toward genetic research: the Ohana (family) heart project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .902 May Vawer, Patsy Kaina, Ann Leonard, Michael Ogata, Beth Blackburn, Malia Young, Todd B. Seto The frequency of HLA alleles in a population of Inuit women of northern Quebec . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .908 Stephanie Metcalfe, Michel Roger, Marie-Claude Faucher, François Coutleé, Eduardo L. Franco, Paul Brassard Access and benefits sharing of genetic resources and associated traditional knowledge in northern Canada: understanding the legal environment and creating effective research agreements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .912 Janis Geary, Cynthia G. Jardine, Jenilee Guebert, Tania Bubela 14


Assessing the social and physical determinants of circumpolar population health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .921 David L. Driscoll, Bruce Dotterrer, Richard A. Brown II Patient and provider perspectives on using telemedicine for chronic disease management among Native Hawaiian and Alaska Native people . . . . . . . . . . . . . . . . . . . . . . .930 Vanessa Hiratsuka, Rebecca Delafield, Helene Starks, Adrian Jacques Ambrose, Marjorie Mala Mau Circumpolar Inuit health systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .937 Leanna Ellsworth, Annmaree O’Keeffe Initial findings from the implementation of a community-based sentinel surveillance system to assess the health effects of climate change in Alaska . . . . . . . . . . . . . . .946 David L. Driscoll, Tenaya Sunbury, Janet Johnston, Sue Renes Pharmaceutical health care and Inuit language communications in Nunavut, Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .955 Sandra J. Romain Susceptibility to hypoxia and breathing control changes after short-term cold exposures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .962 Lyudmila T. Kovtun, Mikhail I. Voevoda Community-based participatory research projects and policy engagement to protect environmental health on St Lawrence Island, Alaska . . . . . . . . . . . . . . . . . . . . . .967 Pamela K. Miller, Viola Waghiyi, Gretchen Welfinger-Smith, Samuel Carter Byrne, Jane Kava, Jesse Gologergen, Lorraine Eckstein, Ronald Scrudato, Jeff Chiarenzelli, David O. Carpenter, Samarys Seguinot-Medina Extended Abstracts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .978 Conference Abstracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1013

Index of Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1025


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The ICCH15 Proceeding is dedicated the memory of Professor Leonid Sevastyanovich Polikarpov

Professor Leonid Sevastyanovich Polikarpov unexpectedly passed away on March 18 2013, in his 69th year of life. Professor Polikarpov was a Russian Doctor of Medicine with Honors, and an active member of the Academy of Circumpolar Health and Extreme Human Ecology. He was a prominent scientist, physician and cardiologist. His work was well known in epidemiology of cardiovascular diseases among indigenous populations and migrants of the Russian Far North. L.S. Polokarpov had shown that extreme ecological factors of high latitudes had different impacts on the cardiovascular systems of migrants that led to development of selection criteria for workers for those regions. Professor Polikarpov authored several significant studies devoted to investigations of risk factors, epidemiology and prognosis of coronary heart disease, heart trauma in diverse ecological conditions, prevalence of arterial hypertension among indigenous and non- indigenous populations of the Russian Far North, and adaptation of cardiovascular systems to extreme ecological conditions.

FOREWORDS

FOREWORD æ

The ugly ducklings that became swans Neil J. Murphy, MD

stood in the wings of the Davis Concert Hall at the University of Alaska, Fairbanks as Dr. Rhonda Johnson’s presented the President’s concluding remarks at the 15th International Congress of Circumpolar Health (ICCH15). Dr. Johnson eloquently hailed the assembled congress for their energy, creativity, and the extra efforts the participants had made to improve circumpolar health. Dr. Johnson praised the customer owners, researchers, and health workers on their attentiveness and pursuit of knowledge. The ICCH15 President likened the ICCH15 participants to beautiful swans gliding across an arctic tarn. Dr. Johnson noted that while swans may appear to effortlessly cruise across the water with their heads held high, under the water their legs are working feverishly to propel them smoothly across the water.

I

When my turn to speak came, I approached the podium of the closing assembly from stage right and gazed out into the same crowd. I was amazed to see not swans, but row upon row of ugly ducklings. As this was a circumpolar event, the 1844 Danish story of Hans Christian Andersen immediately came to mind. Hans spun the story of an ungainly chick born in a duck’s nest. The large, uncoordinated young bird was ridiculed in the farmyard and was of no consequence to the duck community. Over time, through expended energy, creativity, and extra efforts the ugly duckling eventually joined a bevy of mature swans to learn her true lineage. Ultimately the ugly duckling returned to her original pond to be acclaimed a beautiful swan. I realized that the arctic researchers and health workers who presented abstracts had yet to put their work through the peer review process, so were still in fact like that ugly duckling. With their work on these Proceedings, I am proud to announce that the ugly ducklings I saw have become the swans that Dr. Johnson had, in her wisdom, foreseen.

The Canadian Connection These Proceedings are an example of a rigorous academic process in action. The authors honed their rough material from the Congress into full length manuscripts for peer review and sent them to the Associate Editors, who worked with the Assistant Editors. Both reviewed the data and sent it to two Peer Reviewers who made sage academic comments. The evaluations were sent back to the authors who revised their manuscripts accordingly. The revised manuscripts then went through a reversal of the above process to finally be evaluated by a Co-Editor prior to publication. While the organizing of this work product was largely done by the American Society for Circumpolar Health (ASCH), it was inspired by the circumpolar community, most notably by Alaska’s neighbors to the immediate east who hosted the 2009 ICCH14 in Yellowknife, NWT. Susan Chatwood, Co-Chair, ICCH14 Scientific Committee, was unselfish in her advice and influential in the ASCH’s decision to pursue a peer review process. Anne George, Department of Pediatrics, University of British Columbia, moderated the Healthy Families session, gave an invited Featured Presentation on Fetal Alcohol Spectrum Disorder, plus performed yeoman’s work as an Associate Editor of the Healthy Families chapter of the these Proceedings. Sandra Romain, PhD Candidate, Medical Anthropology, University of Toronto, is a rising star in the circumpolar world. Sandra took the bull by the horns and informed me about her interest in academic editing as I emerged from the opening ICCH15 session. As Sandra was the most prolific Assistant Editor, her Associate Editor, Dr. Tom Hennessey, wanted to know if there was a new exalted title we could create just for her. Last, but not least, Kue Young, Editor-in-Chief International Journal of Circumpolar Health, was available to consider our editorial queries at all hours of day and night.

Our ICCH15 Soapbox The circumpolar world covers a lot of territory. It also stretches across multiple nationalities, cultures, and languages. In order to best communicate our ideas we have chosen the English language for both online and hard copy publication. We stand on the shoulders of giants like Jack A. Hildes and Jens Peder Hart Hansen who taught us a mentoring process

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Foreword

whereby new researchers, young and old, must defend their ideas and data through both face-to-face presentation and juried publication. The process can be fraught with numerous pitfalls due to language, different interpretations of the scientific process, and writing skills. The Associate and Assistant Editors of these Proceedings wondered if, in the future, some of these issues could be avoided. Perhaps there could be a Featured Workshop at each ICCH, which did not overlap with other presentations, to inform participants on the process of submitting material to a peer reviewed Proceedings. The workshop could address the basic issues of the scientific method as well as manuscript formatting, e. g., introduction, methods, results, discussion, and conclusion. The workshop could cover preparation of effective tables, figures, and graphics to best illustrate the author’s data. Language issues can hinder the international scientific process. Teams of English speaking researchers could network with those participants who have not published in an English-language journal before. The ICCH15 Editorial team was blessed to have the bilingual Russian/English speaking Marina Dent, Dentist turned graduate student, to mentor many of the primarily Russian-speaking authors. If any of you are ready to give back to the circumpolar health community - that has given so much to you -perhaps you would be willing to share your expertise in these areas at the next ICCH in Oulu, Finland? You too could facilitate the metamorphosis of some ugly ducklings into regal swans gliding across an arctic tarn.

ICCH15 Publication Committee, Chair Alaska Native Medical Center Southcentral Foundation Anchorage, Alaska, USA


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FOREWORD æ

Message from the President of the American Society of Circumpolar Health Rhonda M. Johnson, DrPH, MPH, FNP he 15th International Congress on Circumpolar Health (ICCH 15) held in Fairbanks, Alaska in August 2012 continued a rich tradition of northern exchange and celebration. As the Congress theme ‘‘Circumpolar Health Comes Full Circle’’ suggests, at least some of us have been here before, both literally and figuratively. Each new season brings opportunity to both recognize the achievement of arctic leaders long active in the field, and to welcome the fresh eyes, energy and perspectives of new participants. Since the Symposium on Circumpolar Health Related Problems was first held in Fairbanks, AK in July 1967, the circumpolar health community, much like the region that many of us call home, has evolved, stretched, been under attack, struggled, recovered and both tested and proved its resiliency. Such challenges will not only continue; there is every indication they will greatly increase. This makes our shared commitment to the enduring and potentially exemplary ‘‘One Health’’ of the North so essential.

T

What is ‘‘One Health’’? It is an approach to healing and science that recognizes that human health, animal health and ecosystem health are inextricably linked, and that we have much to learn from the indigenous and aboriginal peoples who have long recognized and honored such ties. The circumpolar health community, through the auspices of both its formal structures and informal networks, has often fostered such holistic and healing perspectives. Building on the rich cultural and socio-ecological diversity across our shared region, the International Union of Circumpolar Health (IUCH) and each of its adhering bodies have provided ample opportunities for scientists, community leaders, health providers, policymakers, educators, and other interested community members to come together and learn from each other. Circumpolar health is the ultimate ‘‘team science’’. Over the past 45 years, the periodic International Congresses have been hosted all around our region, including not only Fairbanks (1967), but also Oulu (1971), Yellowknife (1974), Novosibirsk (1978), Copenhagen (1981), Anchorage (1984), Umea (1987), Whitehorse (1990), Reykjavik (1993), Anchorage (1996), Harstad (2000), Nuuk (2003), Novosibirks (2006), Yellowknife (2009) and now most recently, back to Fairbanks in 2012. We have truly come full circle. Our numbers and areas of foci and interest are growing. There is strength in our numbers and in the diversity of our perspectives. These ICCH 15 Proceedings may help re-capture the warm memories of meeting someone new on a sunny Alaskan summer day, of learning new ways to approach an old problem, or appreciating anew both the beauty and the shared challenges and strengths of our peoples and communities. Ideally, they should also reflect the contributions of many to our northern ‘learning community’ and help engage the next generation of researchers, practitioners, policy makers and leaders in the good work of securing and sustaining circumpolar health for all. President, American Society of Circumpolar Health

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FOREWORD æ

‘‘On Completing the Circle and the Human Health Legacy of the International Polar Year’’ Alan Parkinson, PhD

The Arctic Human Health Initiative is proud to sponsor the Proceedings of the 15th International Congress on Circumpolar Health in partnership with the American Society of Circumpolar Health. The Proceedings of the 15th International Congress on Circumpolar Health were a perfect opportunity to share a final summary report of human health activities conducted during the International Polar year 20072009.

Background The 15th International Congress on Circumpolar Health (ICCH15) was held on the campus of the University of Alaska Fairbanks, August 510, 2012 completing a circle that began 45 years before in 1967 with the first Symposium on Circumpolar Health Related Problems was held on the same campus. The origins of this first Symposium can be traced to the end of the 3rd International Polar Year (195758) called the International Geophysical Year (IGY) which did not have a human health component; but did however provide the catalyst for the beginning of the ‘‘Circumpolar Health Movement’’ a collaborative international effort to focus on human health in the Arctic. In 1957 the Nordic Council appointed a committee for Arctic Medical Research that resulted in the publication of the Nordic Council for Arctic Medical Research Report. Also in 1958, the idea for an International Biological Program was conceived, and it was implemented in 1967 as a biological analog for the IGY, and resulted in the first international circumpolar health symposium was held in Fairbanks, Alaska, in 1967, beginning a tradition of an international meeting on Circumpolar Health to be held every three years in a different circumpolar country, and the eventual formation of the International Union for Circumpolar Health (IUCH). However the 4th International Polar Year (20072009) provided the membership of the IUCH with another opportunity to further reinvigorate cooperation and coordination on Arctic health research, increase the awareness and visibility of human health concerns of Arctic peoples, promote health strategies that will improve health and well-being of all Arctic residents, and develop a long term strategy for addressing Arctic human health concerns. Planning began for an IPY human health initiative at a small September 2004 American Society for Circumpolar Health(ASCH) meeting in Anchorage where members briefly discussed the possibility of using the International Polar Year 20072008 (IPY) to focus attention on Arctic Human Health. Following this meeting, a National Arctic Human Health Initiative advisory committee was formed to develop a National Arctic Human Health Agenda for the IPY. The National Advisory Committee included many ASCH members, representatives from CDC, NIH, Department of State, Alaska Native Tribal Health Consortium, Southcentral Foundation, Alaska Native Science Commission, State of Alaska Division of Public Health, University of Alaska and the Northern Forum. This committee met for the first time in February 2005, to develop specific IPY project proposal ideas. Suggestions included: Using the ICCH13 and 14 to promote the IPY human health agenda and develop a circumpolar health strategy beyond 2009, promote the International Journal for Circumpolar Health (IJCH) as a vehicle for increasing circumpolar health visibility, focus research on infectious diseases, diabetes, obesity and cardiovascular diseases, mental and behavioral health, intentional and non-intentional injury, the effects of environmental contaminants on human and subsistence species health, and impact of climate change on human health. Circumpolar Health Supplements 2013

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Alan Parkinson

The outcome these initial meetings and subsequent, international working group meetings involving the membership of IUCH held during 2005 and 2006, was the development, submission and approval in January 2006 of the ‘‘Arctic Human Health Initiative (AHHI)’’ as a joint IUCH and Arctic Council Sustainable Development Working Group IPY Coordinating project that would build on, and expand the human health agendas of both the Arctic Council and the International Union for Circumpolar Health. The project was aimed at linking researchers with potential international collaborators and to serve as a focal point for human health research, education, outreach, and communication activities during IPY, and to catalogue and monitor the progress of human health projects and activities initiated during the IPY. Further planning of research activities that would be undertaken during the IPY occurred at the 13th International Congress on Circumpolar Health held in Novosibirsk, Russian Federation, June 1216, 2006, the ‘‘Gateway to the International Polar Year’’ for the circumpolar health community and provided a forum for discussion on their respective visions and priorities for human health activities for the IPY and beyond. At the official end of IPY, the 14th International Congress on Circumpolar Health was held in Yellowknife, Northwest Territories, Canada, July 1216, 2009. The theme of the congress recognized the end of the Polar Year and spoke to ‘‘Securing the IPY Legacy: From Research to Action’’. While results from much of the research conducted over the IPY were still pending, the congress program contained a broad cross section of presenters, sessions and preliminary results from the IPY. The sessions allowed for complimentary perspectives of researchers, clinicians, community representatives and governments on numerous topics which impact public health, health services delivery, the research process and Indigenous wellness in our circumpolar regions. Presentations demonstrated instances where research findings are applied in numerous settings, with uptake by clinicians, community organizations and governments. Presentations also recognized the contributions of numerous stakeholders through the research process with a particular focus on community engagement and participatory methods. The 15th International Congress on Circumpolar Health held in Fairbanks August 510, 2012 provided an opportunity to evaluate the progress and success of the IPY and its impact on Arctic Human health and to assess future directions. Research findings from IPY and other projects were presented at the congress, and allowed follow up steps to be planned to take research action and to share practical and applicable health promotion approaches and practices that can be sustained over the long term. For its part the Arctic Council also used the IPY to reinvigorate cooperation and coordination on Arctic health research and during the Norwegian Arctic Council Chairmanship (20062009), created within their Sustainable Development Working Group the Arctic Human Health Expert Group (AHHEG) to the assist the Arctic Council in better coordinating its human health activities, and in February 2011, the Government of Greenland, at the end of the Greenland/Danish Arctic Council Chairmanship, hosted the first Arctic Human Health Ministerial meeting in Nuuk, Greenland. Human health is now a critical component of the Arctic Council’s sustainable development program. The AHHEG will continue to explore ways to ensure greater integration of human health activities, strengthen cooperation and collaborations between Arctic Council working groups and other Arctic cooperatives, and promote the translation of research into actions that will improve the health of all Arctic residents. The AHHI proved to be an effective exercise in identifying and featuring health research activities during IPY, for raising the profile or Arctic human health within national governments and has highlighted the need within the IUCH and the Arctic Council for an ongoing emphasis on, translation of research to action and the development of a strategic direction for addressing critical areas of human health in the Arctic that will improve the health of all Arctic residents. An important part of the AHHI has been outreach, education and communication. The AHHI report lists the many reports and publications that have resulted from the IPY human health activities a testament to the thoughtful and rigorous scientific approach to Arctic health research, report generation and publication of scientific findings. An accomplishment of the ICCH15 has been a return to a juried peer review process for the ICCH15 Proceedings process.

It takes a village AHHI appreciates the insight and thoughtful approach of the Publications Committee which includes: Co-Editors Neil Murphy and Alan Parkinson; Associate Editors Vanessa Hiratsuka, Meera Narayanan, Rhonda Johnson, Mike Brubaker, Anne George, Tom Hennessey, Phil Loring, and Tim Thomas; Assistant Editors Burhan Khan, Cindy Schraer, Anne Lanier, Bree Kessler, Danita Koehler, Julia Smith, Sandra Romain, and Sarah McConnell, and last, but not least Barbara Williams.

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On Completing the Circle and the Human Health Legacy of the International

The AHHI is grateful for the hard work of the Local Organizing committee Co-Chairs, Jacoline Bergstrom and Lawrence Duffy, as well the Committee Members: Sven Ebbesson, Craig Gerlach, Anna Godduhn, Victor Joseph, Sarah McConnell, Tim Murphrey, Mark Miller, Cyndi Nation, Greg Owens, Helen Renfrew, Mary van Muelken, Carla Willetto, and Denise Wartes. The AHHI is thankful the foresight and the extra efforts of the ICCH15 Steering Committee, Chairs Michael Bruce and Rhonda Johnson, as well as the Committee members: Kimberly Rogers, Tammy Zulz, AbbieWilleto Wolfe, Larry Duffy, Mary Van Muelken, Neil Murphy, Thomas Hennessy, Jay Wenger, Laura Banfield, Jennifer Jones, Alan Parkinson, James Berner, Jay Butler, Louisa Castrodale, George Conway, Denise Dillard, David Driscoll, Robert Furilla, Donna Galbreath, Craig Gerlach, Carl Hild, Vanessa Hiratsuka, Michael Klatt, Anne Lanier, Ted Mala, Sarah McConnell, Joe McLaughlin, Karen Miernyk, Ellen Provost, Diana Redwood, Caroline Renner, Barbara Taylor, and last, again but not least Barbara Williams. AHHI also appreciates the hard work the International Journal of Circumpolar Health and Co-Action, esp. Kue Young, Emma Csemiczky, Greta Moreen Wistrand, Lena Wistrand, and Tikoji Rao who provided helpful advice in this process. Lastly, AHHI welcomes the opportunity to partner with the IUCH to further the legacy of improving circumpolar human health as we together journey through until the 2057 IPY. Hang on to your hats, let’s all make it an exciting 44 years!


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John Arthur Hildes Circumpolar Health Awards Since 1987, the Hildes medal has been awarded at each International Congress on Circumpolar Health to distinguished individuals nominated by the adhering bodies of the International Union for Circumpolar Health. More than twenty researchers and health workers from Alaska, Canada, the Nordic countries and Russia have received this award. Between them, the recipients share an unsurpassed volume of knowledge and experience about the Arctic. ICCH15 Hildes Award Winners 2012 Dr. Mikhail Voevoda, Russian Federation Siberian branch of the Russian Academy of Medical Sciences Neil Murphy, MD, USA American Society for Circumpolar Health John David Martin, MD, Canada Canadian Society for Circumpolar Health Inge- Merete Nielsen, MD, Denmark Danish, Greenlandic Society for Circumpolar Health Jon Oyvind Odland, MD, Norway Nordic Society for Arctic Medicine The Jens Peder Hart Hansen Fellow Program The mission of the fund is to foster the ideals of Jens Peder Hart Hansen, to increase international co-operation in circumpolar health research and education by mentoring and encouraging emerging researchers and workers in the field. Starting in 2003, each adhering body has recognized and honored an emerging circumpolar health worker to encourage their continued efforts. The fund emphasizes support of indigenous workers, as defined by each adhering body. Jens Peder Hart Hansen Award Winners 2012 Olga Amelchugova, Russian Federation Siberian branch of the Russian Academy of Medical Sciences Christopher DeCou, USA American Society for Circumpolar Health Tracey Galloway, Canada Canadian Society for Circumpolar Health Ramon Gordon Jensen, MD, PhD, Denmark Danish, Greenlandic Society for Circumpolar Health KetilLenert Hansen, PhD, Norway Nordic Society for Arctic Medicine

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SPECIAL ADDRESSES æ

KEYNOTE PRESENTERS Monday, August 6, 2012 Circumpolar Health Comes Full Circle

Neil Murphy, MD, Southcentral Foundation Neil J. Murphy, M.D. is a past President of the International Union for Circumpolar Health; Past President of the International Union for Circumpolar Health, Co-Chair of the 13th International Congress on Circumpolar Health, President of the American Society for Circumpolar Health; Editor of the ICCH 13 Proceedings, a former Scientific Editor for the International Journal of Circumpolar Health, and is currently the Treasurer of the Arctic Health Foundation (formerly known as the Albrecht Milan Foundation). Dr. Murphy is a graduate of the University of Alaska at Fairbanks. He subsequently attended the University of Washington - WWAMI Medical School Program. Dr. Murphy works clinically for the Southcentral Foundation Department of OB/GYN at the Alaska Native Medical Center (ANMC) in Anchorage, Alaska. At ANMC since 1993, he had worked as a Board Certified Family Physician in the Indian Health Service in Bethel and Sitka, Alaska since 1985. Dr. Murphy was the national OB / GYN Chief Clinical Consultant for the Indian Health Service from 20002008. He has presented at the ICCHs since 1987 on interests which include: history of circumpolar health, glucose intolerance in Alaska Native People, and the impact of the human papilloma virus vaccine.

Circumpolar Health - What’s Next?

Kue Young, MD, PhD, University of Toronto, Canada Kue Young is Professor of Public Health at the University of Toronto, Canada. He has a long association with circumpolar health. He first attended the 5th Circumpolar Health Congress in Anchorage in 1984, Circumpolar Health Supplements 2013

and has not missed a single one since then, although in more recent years his role in the congresses has primarily been that of a tourist. He was President of both the Canadian Society and the International Union for Circumpolar Health from 19931996. He received the Hildes Medal in 2000. In 2005 he founded the International Network for Circumpolar Health Research and served as its president until 2012. Beginning in January 2012 he took over the job of Editor-in-Chief of the International Journal for Circumpolar Health as the journal enters a new era as a completely online journal. Within Canada, Kue Young’s contributions to Aboriginal and circumpolar health research is widely recognized, for which he was inducted a Fellow of the Canadian Academy of Health Sciences in 2009 and a Member of the Order of Canada in 2010.

Tuesday, August 7, 2012

Children Exposed to Domestic Violence: Implications and Opportunities for Circumpolar Health

Linda Chamberlain PhD, MPH Scientist, author, professor, dog musher, and founder of the Alaska Family Violence Prevention Project with the State of Alaska, Section of Chronic Disease Prevention and Health Promotion, Dr. Linda Chamberlain is an internationally recognized keynote speaker and champion for health issues related to domestic violence, children exposed to violence, brain development and trauma, and the amazing adolescent brain. She is known for her abilities to translate science into practical information with diverse audiences and convey a message of hope and opportunity. Dr. Chamberlain holds faculty appointments at the University of Alaska and Johns Hopkins University. She earned her public health degrees from Yale School of Medicine and Johns Hopkins University. The author of numerous publications and domestic violence training resources including the Public Health Toolkit, the Amazing Brain booklets for parents, the Reproductive Health and Violence Guidelines, and a train-the-trainer curriculum for home visitors, Dr. Chamberlain is editor for the e-journal, Family Violence Prevention and Health Practice and serves on the National Advisory Board for the Institute for Safe Families. Awards and recognition for her work include a National Kellogg Leadership Fellowship.

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Keynote Presenters

Developing Healthy Communities: Understanding the Determinants of Early Inuit Health in Nunavut Laura Arbour, PhD, University of British Columbia Dr. Laura Arbour is a Professor in the Department of Medical Genetics at the University of British Columbia and the UBC Island Medical Program in Victoria, BC. Trained as both pediatrician and clinical geneticist (McGill University), her research integrates maternal child health issues and the understanding of the genetic component to aboriginal health of all ages, such as congenital heart defects in the Inuit of Nunavut; Long QT Syndrome in Northern British Columbia, and the potential risk of CPT1A P479L for infant mortality in northern populations. She works closely with northern partners building and enhancing congenital anomaly and birth outcome surveillance tools including, most recently, the population based ‘Nutaqqavut (our children)’ Health Information System for Nunavut. Currently she is also the clinical lead of Medical Genetics for the Vancouver Island Health Authority in British Columbia.

Wednesday, August 8, 2012 Arctic Research: How Does Health Fit In?

Fran Ulmer, U.S. Arctic Research Commission Fran Ulmer is the Chair of the U.S. Arctic Research Commission. She recently retired as Chancellor of the University of Alaska Anchorage. In June 2010 she was appointed by President Barack Obama to the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling. The commission was charged with investigating the causes of the explosion and oil spill, and recommending changes to prevent future disasters from occurring. Prior to her appointment to the commission, Ms. Ulmer was a member of the Aspen Institute’s Commission on Arctic Climate Change and held Board positions with the Alaska Nature Conservancy, the National Parks Conservation Association and the Union of Concerned Scientists. Prior to being appointed Chancellor in 2007, Ms. Ulmer was a Distinguished Visiting Professor of Public Policy and Director of the Institute of Social and Economic Research at UAA. Ms. Ulmer served as an elected official for 18 years as the mayor of Juneau, a state representative and as

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Lieutenant Governor of Alaska. As Director of Policy Development for the State of Alaska, Ms. Ulmer managed multiple Programs and served as the first coChair of the Alaska Coastal Policy Council. At the national level, Ms. Ulmer served for more than 10 years on the North Pacific Anadromous Fish Commission; as a member of the Federal Communications Commission’s State and Local Advisory Committee and the Federal Elections Commission’s State Advisory Committee and co-chaired the National Academies of Science’s Committee on State Voter Registration Databases. Ms. Ulmer earned a J.D. cum laude from the University of Wisconsin Law School, and has been a Fellow at the Institute of Politics at the Kennedy School of Government.

When an Entire Country is a Cohort Study Mads Melbye, MD, DMSc, Professor in Epidemiology and Executive Vice President, Statens Serum Institut Mads Melbye, MD, DMSc, is Professor in Epidemiology and Executive Vice President, Statens Serum Institut. He has held research positions in epidemiology in Denmark and at the National Cancer Institute, NIH, USA, before he became State Epidemiologist, and later Professor and Head of Department of Epidemiology Research, and Director of Division of Epidemiology, Statens Serum Institut, Copenhagen. He has obtained academic positions as NORFA professor and Foreign Adjunct Professor at Karolinska Institute, Stockholm, Sweden. He has written more than 430 publications and has an H-index of 60. He holds the record within Denmark of having most papers in high impact journals in general medicine (NEJM, Lancet, JAMA). He is associate editor of Journal of the National Cancer Institute, an editor of an international handbook on AIDS, and editorial board member of several scientific journals. He has e.g. been chairman of the Nordic Medical Research Council’s coordinating body (NOSM) (200710), vice-chairman of the Danish Medical Research Council (200610) and is presently e.g. chairman of the Danish Health Insurance Fond, chairman of the Ministry of Science, Technology and Innovation’s committee on Registry Research (KOR), and vice-chairman, board of Scientific Councillors, International Agency for Research on Cancer (IARC), Lyon, France, and member of the Swedish Ministry of Science’s infrastructure committee. He is a member of several committees advising Government on issues relating to Health and Science. Circumpolar Health Supplements 2013

Keynote Presenters

Thursday, August 9, 2012 Vulnerable Populations. Health of Humans and Animals in a Changed Landscape

Birgitta Evenga˚rd, MD BirgittaEvenga˚rd became MD in 1979 at KarolinskaInstitutet in Stockholm, Sweden where she also did her thesis (1989) and became an associate professor in infectious diseases in 1997 and professor of clinical parasitology in 2006. In 2007 she was appointed the first woman with a chair in infectious diseases in Sweden at Umea˚university. She is a specialist in infectious diseases (1991) and clinical immunology (1994) and in clinical parasitology. She has been senior consultant since 1994. Her research has been focused on parasites (Schistosoma and Toxoplasma gondii) and fatigue science egunwellness after infections. She has worked with large databases as the Swedish twin registry and performed molecular epidemiological studies from a public health perspective as well as improved diagnostics of parasitic diseases using molecular techniques. She has initiated a European study group on clinical parasitology and participates in several international scientific networks. She has also led a project initiated by politicians on gender equality in the health care system and has interacted with society in many debate articles, as well as being the author of 9 books and 17 chapters in teaching books.

Wellness Teams - A Community Approach to Suicide Prevention

Cyndi Nation, Conference

Tanana

Chiefs

Cyndi Nation, KoyukonAthabascan, serves as the Community Health Outreach Program Director for the Tanana Chiefs Conference. The Tanana Chiefs Conference is a non-profit organization with a membership of Native governments from 42 Interior Alaska communities. The full Board of Directors are 42 representatives selected by the village councils of member communities. The Tanana Chiefs Conference has almost three hundred and fifty full-time employees and numerous part-time and seasonal positions. About two-thirds of the staff members work in village positions, and about two-thirds of the employees are Alaska Native. Cyndi not only provides Home Care Services to 42 of Alaska’s Interior villages, but also oversees the Community Health Representative Program and Health & Safety Education. In the last two years she has also been actively involved in Circumpolar Health Supplements 2013

Suicide Prevention activities in the Interior. Her parents are Richard D. Smith Sr. (Smitty) and Ethel E. Evans Smith. Her father is originally from Simms, Texas and her mother is from Rampart, Alaska. Cyndi grew up in Fairbanks but spent many summers at their fish camp just outside of Rampart. She has three beautiful grown daughters and several grandchildren located in Fairbanks and Anchorage.

Friday, August 10, 2010 Common Solutions

Problems,

Uncommon

Lt. Governor Mead Treadwell, State of Alaska Mead Treadwell was elected as Alaska’s lieutenant governor in November 2010. He is committed to helping Governor Sean Parnell strengthen Alaska’s economy by filling the Trans Alaska Pipeline System, seeing a gas pipeline get gas to Alaskans and markets beyond, bringing affordable energy to Alaskans and securing access to our natural resources. Treadwell is recognized as one of the world’s Arctic policy experts. He was appointed to the United States Arctic Research Commission by President George W. Bush in 2001 and designated by the president as the commission’s chair in 2006. Under his leadership, a new United States Arctic policy was developed and adopted by President Bush and is now being implemented by the current administration. Treadwell was Cordova’s director of oil spill response during the Exxon Valdez oil spill crisis, and served as Governor Wally Hickel’s Deputy Commissioner for the Department of Environmental Conservation, where he helped to develop Alaska’s oil spill regulations and established the environmental crime unit for the state. As a private entrepreneur and investor, he helped launched a series of technology, manufacturing and service companies.

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FEATURED TOPIC PRESENTERS

Patricia Longley Cochran, Alaska Native Science Commission Patricia Cochran was born and raised in Nome, Alaska. Ms. Cochran serves as Executive Director of the Alaska Native Science Commission, an organization that brings together research and science in partnership with Alaska Native communities. Ms. Cochran also served as Chair of the 2009 Indigenous Peoples’ Global Summit on Climate Change and is Co-Chair of the Indigenous Peoples’ Global Network on Climate Change. She is the past Chair of the Inuit Circumpolar Council, an international organization representing 160,000 Inuit of Alaska, Canada, Russian and Greenland; and former Chair of the Indigenous Peoples’ Secretariat to the 8 nation, Arctic Council.

(UBC); Associate Member, School of Population and Public Health, UBC; Adjunct Professor, University of Northern British Columbia; and Research Affiliate, Centre for Addictions Research BC. Her office is located in northern British Columbia where she focuses on public health research of northern populations. She is Principle Investigator on a study of injury in Aboriginal communities, and co-investigator on various populationbased studies, including a national longitudinal study of the health of immigrant and refugee children to Canada, the New Canadian Children and Youth Study. She has a particular interest in ethical practice and in ethics review of community-based research. A recent paper, Review of procedures for approval of health studies in Northern Canada, was published in IJCH 70(4):341 440, 2011.

Craig Gerlach, PhD, University of Alaska Fairbanks Eileen Dunne, MD, US Centers for Disease Control & Prevention Dr. Eileen Dunne joined CDC in 1998 as an Epidemic Intelligence Service Officer. She graduated from Tulane Medical School and completed an internal medicine residency at OHSU, followed by an infectious diseases fellowship at University of Colorado. Since 2001, Dr. Dunne has worked in the Division of STD Prevention, CDC and focused on HPV and HPV vaccine research, policy and implementation issues. Dr. Dunne helped develop recommendations for the quadrivalent and bivalent HPV vaccines in her role on the ACIP HPV Workgroup. She has co-authored more than 50 publications. Dr. Dunne is a Captain in the US Public Health Service.

Craig Gerlach is a Professor in the Center for Cross Cultural Studies at the University of Alaska Fairbanks. Dr. Gerlach currently researches the relationship between food, culture and human health, with an ongoing interest in food and water systems, sustainable livelihoods and community well-being, nutritional ecology, and sustainable, small scale, high latitude farming and food production systems. Dr. Gerlach has worked throughout Alaska, in northern Europe, Mexico and Africa, and also has a long history of involvement with environmental impact assessment, oil spill litigation, and with studies of the impacts of industrial development on community health and Alaska Native subsistence and food systems.

Katherine Gottlieb, Foundation Anne George, PhD, University of Northern British Columbia Dr. Anne George is an Assistant Professor, Pediatrics, Faculty of Medicine, University of British Columbia

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Southcentral

Katherine Gottlieb, MBA, has served as president and CEO of Southcentral Foundation (SCF) since 1991. Under her direction and guidance, SCF has become a leader among the nation’s health care organizations. Circumpolar Health Supplements 2013

Keynote Presenters

She serves on numerous boards, including the National Library of Medicine Board of Regents, and remains active at the national level in Alaska Native and American Indian policy issues. In 2004, she was a recipient of the MacArthur ‘‘Genius Award’’. In 2005, she received an honorary doctoral degree, a doctor of public service, honoriscausa, from Alaska Pacific University in recognition of her extraordinary public service.

Victorie Heart, MS, RN, Alaska Native Tribal Health Consortium Victorie ‘‘Torie’’ Heart, MS, RN is currently the Director of the Community Health Aide Program for Alaska Native Tribal Health Consortium. In this position, she and her staff provide consultative services on all aspects of Alaska’s unique Community Health Aide Program: administer the CHAP Certification Board, operate one of four CHAP Training Centers, and help manage the first Dental Health Aide Therapist training program in the US. She has been involved in tribal health care in Oregon and Alaska for over 25 years.

Jack He´bert, Cold Climate Housing Research Center Jack He´bert is President, CEO, and founding Chair of the Cold Climate Housing Research Center (CCHRC), an organization committed to promoting safe, affordable, durable, and energy efficient housing for cold climate regions. As owner of He´bert Homes, LLC, Jack has been designing and building homes in Alaska for over 30 years. Jack has received numerous honors including a 2010 Cascadia Fellowship for his contributions to sustainable building design and science, the first State of Alaska Governor’s Award for Excellence in Energy Efficient Design, and the Energy Rated Homes of Alaska President’s Award. He was twotime Alaska State Homebuilder of the Year and served as the National Association of Homebuilders (NAHB) National Vice Chair for the five Northwest states. Jack has addressed the U.S. Senate Subcommittee on Energy and been an invited speaker to many conferences in North America, most recently in Scandinavia and Greenland. Circumpolar Health Supplements 2013

Travis Holyk, Carrier Sekani Family Services Travis Holyk is the Director of Research and Policy Development for Carrier Sekani Family Services, an organization responsible for health, social, research and legal services for First Nations people of the Carrier and Sekani territory (North Central British Columbia). As the Director of Research, he currently oversees a number of research grants held by the Agency as well as university-agency research partnerships. He completed his Doctorate in Education at Simon Fraser University and is an Adjunct Professor at the University of Northern British Columbia. Travis penned the CSFS Research Ethics Policy guiding research involving Carrier Sekani communities and has conducted a considerable amount of research into health and social issues impacting First Nations peoples. Current research initiatives include primary healthcare, youth suicide, child welfare governance and research ethics.

Ward B. Hurlburt, MD, MPH, Alaska Department of Health and Social Services Dr. Ward B. Hurlburt serves as chief medical officer for the Department of Health and Social Services and director of the Division of Public Health. Before moving to the private health sector, Hurlburt served more than 30 years with the U.S. Public Health Service, including long assignments in Alaska and several years as an assistant surgeon general. In his 32-years with the Public Health Service, Hurlburt served as hospital administrator in Dillingham, hospital administrator and chief of surgery at the Alaska Native Medical Center, and as deputy director of the Alaska Area Native Health Service. He considered Alaska his home from 1961 to 1993 when he retired from the Indian Health Service. Before moving back to Alaska in June 2009, he worked as vice president, chief medical officer and consultant for managed care organizations in Washington, Utah and Oregon.

Michael Jong, University

MD,

Memorial

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Keynote Presenters

Dr. Michael Jong is a rural physician who has worked in Labrador amongst Indigenous peoples for the past 30 years. He is the Vice President of MedicalServices for Labrador Grenfell Regional Health Authority and Professor of Family Medicine at Memorial University. He was given the Gus Rowe award for the best family medicine teacher of the year at Memorial University in 1993. He received Memorial University’s community teaching award in 2006 and was chosen as one of the family physicians of Canada in 2006. He received the Canadian Family Physicians of Canada award of excellence in teaching in 2007. Dr. Jong has been doing research mainly to discover ways to solve the health problems in Labrador. To date he has been involved in grants totaling more than $1 million, 50 publications andpresented 100 papers locally and internationally.

Epidemiology Research at Statens Serum Institut, Copenhagen, where he took his PhD and MPH degrees on infectious disease subjects. As a senior researcher Dr. Koch heads the Section for Greenland Research at the Department of Epidemiology Research, having coauthored more than 60 peer-reviewed papers mainly on infectious diseases in Greenland, and supervised nine PhD students. In addition to research Dr. Koch trains for a specialist degree in clinical Infectious diseases at Copenhagen University hospitals.

Donald A.B. Lindberg MD, National Library of Medicine

Debra Keays-White, BA, BN, RN, MScN, Health Canada Debra has worked in partnership with the First Nations and Inuit of Atlantic Canada for the past ten years. Her 32 year career in health has spanned most areas in clinical nursing, as well as health policy and administration. She has worked in all four Atlantic provinces, as well as in British Columbia and Ottawa. While working as a Public Health Nurse in Terrace, BC, her district included coverage of Stewart BC and Hyder, Alaska. Debra has studied at UPEI, UBC, completed both her BA (English and History) and BN at UNB Fredericton, then her MScN at the University of Edinburgh, Scotland, in Health Policy with a focus on ethics and health economics. She is an Adjunct Professor at Dalhousie University School of Nursing. Debra led a team that won Health Canada’s Deputy Minister’s Award for Innovation and Creativity (2011) and the Assistant Deputy Minister’s award for Contribution to Improving the Health of Canadians (2011) for this telerobotics demonstration project.

Dr. Donald A.B. Lindberg, a distinguished professor of pathology and the founding father of the discipline now known asmedical informatics, pioneered in applying computer technology to medicine at the University of Missouri, nurtured the discipline to its present eminence, and in 1984 translated his professional and organizational skills to a national level in leading the National Library of Medicine and opening up its vast information resources to all via the World Wide Web. He has a strong commitment to extending the benefits of health information technology to all sectors of society, especially in rural, remote, minority, and underserved communities. Dr. Lindberg is a leader in the Federal Networking and Information Technology Research and Development (NITRD) initiative to improve health and health care. Lindberg served from 1992 to 1995 as the founding Director of the White House High Performance Computing and Communications Program, predecessor to NITRD.

Philip Loring, PhD, University of Alaska Fairbanks

Anders Koch, MD, Department of Epidemiology ResearchatStatens Serum Institute Dr. Anders Koch graduated in 1991 as MD from the University of Copenhagen, Denmark. In 1994 after medical intern ships he joined the Department of

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Philip Loring is a research assistant professor at the Institute for Northern Engineering, where he runs the Human Dimensions Lab at the Water and Environmental Research Center. He is a human ecologist with training in anthropology, ecology, and indigenous studies. He has worked across Alaska as well as Northwest Mexico and Guatemala. He currently works with students on a number of projects relating to fisheries, community food production, and food and water security. Circumpolar Health Supplements 2013

Keynote Presenters

Ted Mala, MD, MPH, Southcentral Foundation Dr. Ted Mala has been at Southcentral Foundation for the past decade serving as Director of Traditional Healing and Director of Tribal Relations. As an Alaska Native Inupiat Eskimo enrolled in the Village of Buckland as well as the Northwest Arctic Native Association (NANA) in Kotzebue, he integrates those values with his Russian heritage to assist other Native people to ‘‘walk in two worlds with one spirit’’. He lectures on circumpolar medicine as well as the role of Native Americans in health research. He is a frequent visitor to Hawaii collaborating with the Department of Native Hawaiian Health at the John A. Burns School of Medicine at Honolulu. He is the past president of the Association of American Indian Physicians and recently was elected Native American Physician of the Year by his fellow American Indian Physicians. A former COPR member advising the Director of NIH, he now continues in that role with various NIH institutes and centers. He is one of the original founders of the International Union of Circumpolar Health.

Ivar Mendez, MD, PhD, FRCSC, FACS Dr. Ivar Mendez is a Professor of Neurosurgery, Anatomy and Neurobiology at versity and the Queen Elizabeth Health Sciences Centre in Halifax, Canada. As a Clinician/ Scientist, Dr. Mendez’s research focus is in functional neurosurgery, brain repair and remote presence telemedicine. For the past decade he has worked in the use of remote-presence robots for medical care in neurosurgery and primary care in remote communities of the Bolivian Andes and the Canadian Arctic. In 2002, Dr. Mendez and his team performed the first long distance telementoring neurosurgery in the world. In 2010, Dr Mendez received the Humanitarian of the Year Award by the Canadian Red Cross for his humanitarian work in global health.

Matt Moore, MD, MPH, US Centers for Disease Control & Prevention Circumpolar Health Supplements 2013

Dr. Moore is trained in internal medicine and infectious diseases with additional training in CDC’s Epidemic Intelligence Service Program. He became the principal investigator of CDC’s Active Bacterial Core surveillance pneumococcal disease program in 2006. He is responsible for studies aimed at evaluating the public health effects of the introduction of pneumococcal conjugate vaccine in 2000 and 13-valent conjugate vaccine in 2010. These effects include the impact of the vaccination program on invasive pneumococcal disease incidence, on antibiotic resistance, and on the emergence of non-PCV7 serotypes. He is CDC’s principal investigator on the evaluation of the effectiveness of 13-valent pneumococcal conjugate vaccine.

Alan Parkinson, PhD, US Centers for Disease Control & Prevention Alan Parkinson Ph.D is currently Deputy Director of Center for Disease Prevention and Control’s Arctic Investigations Program, a field station within the Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases, located in Anchorage, Alaska. Dr. Parkinson earned his Ph.D. degree in microbiology in 1976 from Otago University, Dunedin, New Zealand, and undertook a post doctoral fellowship at the Oklahoma University Health Sciences Center. He joined CDC in 1984. Dr Parkinson has been instrumental in establishing the International Circumpolar Surveillance system, an Arctic Council Sustainable Development Working Group project for monitoring infectious diseases in the Arctic, and coordinates the Arctic Human Health Initiative, a US led, Arctic Council International Polar Year project.

Troy Ritter, Alaska Native Tribal Health Consortium Troy Ritter manages the Alaska Native Tribal Health Consortium’s Applied Sciences Unit. This unit includes the newly-formed National Tribal Water Center. He has been working to address water and sanitation issues in Alaska Native communities since 1999. Troy is a Registered Environmental Health Specialist and a Diplomat of the American Academy of Sanitarians.

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Keynote Presenters

partnerships and collaborative efforts to address the many health concerns facing Alaska Native people and is committed to involving communities in the process. Listed below are some of her current leadership responsibilities: Rheanna Robinson, University of British Columbia Ms. Rheanna Robinson is a PhD student in the Department of Educational Studies at the University of British Columbia and has worked in the University of Northern British Columbia’s Office of Research and Graduate Programs (ORGP) since February 2008 as a Research Project Officer and Ethics Coordinator. In her role with the ORGP at the University of Northern British Columbia, facilitating effective community collaborations and research partnerships holds particular importance to her both personally and professionally. As a busy mother of two small children, she understands the importance of giving-back and community relations and is pleased to have the University of Northern British Columbia positioned to foster those ideals.

. Health Representative from the Native Village of Ekuk . Bristol Bay Area Health Corporation Board of Directors; Chairman of the Board . Alaska Native Health Board, Board of Directors . National Indian Health Board, Alaska Representative . Alaska Native Tribal Health Consortium, Board of Directors; Vice Chairman . Alaska Native Medical Center Joint Operating Board; Chairman . Health Research Advisory Council, Division of Health and Human Services National Board . Health Research Review Committee, Alaska Native Tribal Health Consortium; Chairman She is the mother of four grown sons and has five grandchildren.

Cheryl Rosa, US Arctic Research Commission Dr. Cheryl Rosa currently serves as the Deputy Director of the US Arctic Research Commission and as the Director of its Alaskan office. Dr. Rosa received a Doctorate in Veterinary Medicine from Tufts University and a Doctorate in Biology from the University of Alaska Fairbanks. She was formerly a Research Biologist and Wildlife Veterinarian for the North Slope Borough (NSB) Department of Wildlife Management in Barrow, Alaska.

Crystal Stordahl PA-C, Tanana Chiefs Conference

MMSc,

Ms. Crystal Stordahl grew up in rural Interior Alaska and has worked for Tanana Chiefs Conference in various capacities of their rural health services department and Community Health Aide Program (CHAP) for over 11 years. As the CHAP Director she works with 24 rural clinics and over 70 staff for the delivery of primary, preventive and emergency medical services.

H. Sally Smith, Alaska Native Tribal Health Consortium, Board of Directors; Vice Chairman Ms. H. Sally Smith, a Yup’ik Eskimo from Dillingham, has served as a health care advocate and leader for fortyfive years. Ms. Smith works to bring the health challenges and success stories of Alaska Native people to the attention of government leaders, policy makers, funding agencies, academic institutions and to Alaska Native and American Indian people. She is focused on forming

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Gail T. Turner, RN, BN, MAdEd, CCHN Gail Turner is a beneficiary of the Labrador Inuit Land Claim who has recently retired as Director of Health Services for Nunatsiavut Government, where she was responsible for public health, home and community care and Non Insured Health Benefits. She has worked in her Circumpolar Health Supplements 2013

Keynote Presenters

native Labrador for twenty six years in both clinical and management roles that included the community clinics, public health, continuing care and medical evacuations. She received her Bachelor of Nursing from Memorial University of Newfoundland in 1973, a Masters of Adult Education from St. Francis Xavier University, Nova Scotia in 1993, a Diploma in Health Administration from Canadian Healthcare in 1997, and Certification in Community Health Nursing from CAN in 2008. She was the recipient of the Health Canada Award of Excellence in Nursing, 2007. Gail has represented Inuit health at regional, provincial, national and international forums and continues to sit on five national committees and work for Inuit within her consultancy. She celebrates being Inuit and uses every opportunity to share who we are, where we are and why we stay, and is a strong advocate for bringing health service to the Inuit where they live.


Marilyn Van Bibber, Arctic Institute of Community-Based Research Marilyn Van Bibber belongs to the wolf clan of the Northern Tutchone people and is a member of Selkirk First Nation at Pelly Crossing, Yukon. Marilyn began her career as a registered nurse with a certificate in nurse midwifery. She has extensive experience in Aboriginal health development including, research and program development. Marilyn has a long standing commitment to Aboriginal community health issues and the promotion of healthy families. She believes that the key to selfdetermination in Aboriginal communities is in the healthy development of the next generation.

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The Publications Committee welcomes you to the ICCH15 Proceedings! The ICCH15 Steering Committee and Publications Committee chose to re-introduce a juried peer review evaluation system to the ICCH Proceedings process. The peer review process began with the Session Moderators nominating presentations from each Session based on these criteria: -Scientific method -Relevance to circumpolar health -Respect for culture -Clarity of presentation Each full length manuscript was then evaluated by the team of Editors (See Publications Committee) and then sent to content experts for review. The acceptance rate was approximately the same percent as the usual International Journal of Circumpolar Health acceptance rate. How are the ICCH15 Proceedings organized? The Plenary and Featured Speakers’ Chapters are organized in this order: -Full length peer reviewed manuscripts -Presentations synopses Likewise the eight scientific chapters are organized in this order: -Full length peer reviewed manuscripts -Extended abstracts -Conference abstracts The ICCH15 Publications Committee encourages you to join on us a journey through breadth and depth of the experience shared at the ICCH15. All Aboard!

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CHAPTER 1. Plenary Sessions

PLENARY SESSIONS æ

The roundtrip to Fairbanks: the circumpolar health movement comes full circle, part II Neil J. Murphy* Southcentral Foundation, Alaska Native Medical Center, AK, USA

Objectives. Evaluate the course of the International Union for Circumpolar Health (IUCH) and the Proceedings of the International Congress(s) on Circumpolar Health (ICCH) in the context of the concomitant historical events. Make recommendations for future circumpolar health research. Study design. Medline search and historical archive search of ICCH Proceedings. Methods. Search of all PubMed resources from 1966 concerning the circumpolar health movement. Two University of Alaska, Anchorage Archive Collections were searched: the C. E. Albrecht and Frank Pauls Archive Collections. Results. Fourteen sets of Proceedings manuscripts and one set of Proceedings Abstracts were evaluated. There was a trend towards consistent use of the existing journals with indexing in Index Medicus; shorter intervals between the Congress and Proceedings manuscript publication; and increased online availability of either the Table of Contents or Proceedings citations. Recent additions include online publication of full-length manuscripts and 2 instances of full peer-review evaluations of the Proceedings manuscripts. These trends in Proceedings publication are described within the course of significant events in the circumpolar health movement. During this period, the IUCH funds are at an all-time low and show little promise of increasing, unless significant alternative funds strategies are pursued. Conclusions. The IUCH has matured politically over these years, but some of the same questions persist over the years. There has been a trend towards more rapid dissemination of scientific content, more analytic documentation of epidemiologic study design and trend towards wider dissemination of scientific content through the Internet. Significant progress in each of those areas is still possible and desirable. In the meantime, the IUCH should encourage alternative funding strategies by developing a foundation to support on-going expenses, for example Hildes awards; explore venues to finance Council President and At-Large members travel costs; and seek grants to fund special projects, for example special supplements in the IJCH. Keywords: circumpolar health; history; Congress Proceedings; health research; International Polar Year

n hosting the 15th International Congress on Circumpolar Health (ICCH), the American Society for Circumpolar Health (ASCH) welcomed the circumpolar health movement back to Fairbanks for the first time since 1967. It had been 45 years since the original Symposium on Circumpolar Health-Related Problems was held in Fairbanks, Alaska. The following is an effort to explore some of the changes in circumpolar health in those many intervening years. At the outset, let us look at some of the current International Union for Circumpolar Health (IUCH) issues. You may then be able to help the circumpolar health movement decide on how to proceed in its next 45 years. Ironically, these questions have been asked many times during the interim:

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(a) In a rapidly changing Arctic, how can the IUCH best serve the circumpolar health movement? (b) Should the IUCH function as a research funding broker? (c) Should the IUCH become an individual membership organization? (d) and many more . . ..

Background Our understanding of high-latitude processes has increased since the first International Polar Year (IPY) in 18821983. In 19571958, the International Geophysical Year focused the rest of the planet’s attention on the many resources and ambiguities of the Polar Regions. The International Geophysical Year 19571958 involved

Citation: Int J Circumpolar Health 2013, 72: 21608 - http://dx.doi.org/10.3402/ijch.v72i0.21608

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80,000 scientists from 67 countries, yet human health was not a major area of study. Fifty years later, the circumpolar health community saw the first IPY that included an emphasis on human health. This change in the 20072008 IPY research agenda was, in large, the result of the movement of scientists/health workers who have gathered every 3 years since 1967 to improve human health in the circumpolar areas (1). The circumpolar health movement began in the coldest era of the Cold War. The increased interaction of circumpolar scientists and health workers temporally coincided with a process of thawing distrust and conflict.

The seminal leaders In the same year as the 19571958 International Geophysical Year, the Nordic Council appointed a committee for arctic medical research, which began a process that culminated with the Nordic Council for Arctic Medical Research (NCAMR) Report. The first exploratory human health conference was sponsored by the World Health Organization (WHO) in Geneva from 28 August to 1 September 1962 (2). The WHO Conference on Medicine and Public Health in the Arctic and Antarctic concluded that there was an urgent need to stimulate high-latitude research, especially on health problems. Another impetus that inspired the circumpolar health movement was the Human Adaptability Section of the International Biologic Programme (19641974) (3). Fred Milan, a Human Research Physiologist with the Arctic Aeromedical Laboratory for the US Air Force in Fairbanks, coordinated the arctic volume. As a result of these combined processes, the organization of regular symposia on circumpolar health was agreed upon (4). The first international symposium The first person to organize an international circumpolar health symposium was C. Earl Albrecht in Fairbanks, Alaska, in 1967. C. Earl Albrecht, former commissioner of Health for the State of Alaska, envisioned an IUCH for over a decade before the first international meeting became a reality. With the help of the Arctic Institute of North America, the 1967 Symposium on Circumpolar Health-Related Problems had participants from the USSR, Canada, Norway, Denmark, Sweden, Greenland, Iceland and Finland. It was in this symposium that an informal international affiliation was formed. In the 1967 meeting, the decision was made to hold a symposium every 3 years, each in a different country. Twenty years later, these symposia were reorganized to ‘‘Congress’’(s), to reflect the formation of the IUCH. At the 1967 Fairbanks meeting, an informal organization of the future ASCH was formed. C. Earl Albrecht, with the assistance of Fred Milan and other Alaskan scientists, held this organization together primarily to participate in future international symposia.

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Early international symposia for circumpolar health There were approximately 100 scientists present at the first symposia held in Fairbanks, Alaska, 2328 July 1967 (5). The 2nd International Symposium for Circumpolar Health was held from 21 to 24 June 1971 in Oulu, Finland (6). The President of the Symposium was Ole WaszHockert and the chairman of the scientific committee was Henrik Forsius. For almost 2 years leading up to the 2nd Symposium, the entire activities of the NCAMR concentrated on the upcoming symposium (7). The 3rd International Symposium for Circumpolar Health was held from 8 to 11 July 1974 in Yellowknife, Canada (8). The symposium was organized by Otto Schaefer, and Jack Hildes was the Chairman of the Scientific Program. This was the first symposium to feature a specific nutrition section, with nutrition topics also included in nearly every section, for example cardiovascular, blood lipids, and dietary habits of children (9). The 4th Symposium was held in Novosibirsk, USSR, 27 October 1978 with V. P. Kaznacheev, Academician of the USSR Academy of Medical Science, Novosibirsk, as Chairman (10). The symposium was sponsored by the Regional Office for Europe of the WHO. There were 330 reports on the current circumpolar health problems. Two volumes of abstracts were published, in English and Russian, for example not full-length manuscripts. In this context, the FinnishRussian relationships proved to be very useful. During the preparation for the 4th Symposium, Professor Ole Wasz-Hockert made several visits to Russia (11). Denmark hosted the 5th International Symposium for Circumpolar Health from 9 to 13 August 1981 in Copenhagen with over 300 participants formally registered from 17 countries. Bent Harvald was President and Jens Peder Hart Hansen was the General Secretary (12). Scientists came from as far as Argentina and Australia to share Antarctic activities (13). This symposium exposed the practical difficulties, and especially the financial obstacles, in organizing a conference of that size without a financially responsible organization. This was the direct motivation for the formation of a collaborative structure and ultimately resulted in the formation of the IUCH. The maturation process: a circumpolar health ‘‘movement’’ In 1982, C. Earl Albrecht announced progress in the formation of a future IUCH (14). Four adhering bodies had formed for the purpose of guaranteeing quality representation at the International Symposia including the newly formed ASCH and the Canadian Society for Circumpolar Health, with the previously existing Organization of NCAMR and Siberian Branch of the USSR Academy of Medical Science (15). The 6th International Symposium on Circumpolar Health was hosted by the ASCH and was held in


The roundtrip to Fairbanks

Anchorage, Alaska in 1721 May 1984 (16). The American Public Health Association eventually produced ‘‘The National Arctic Health Science Policy’’ as a result (17).

The International Union for Circumpolar Health The concept of an IUCH was agreed upon at the Copenhagen Symposium in 1981. At the Anchorage symposium in 1984, the main principles were agreed upon and NoSAMF was tasked with finalizing the principles (3). The IUCH’s first official organizational meeting was held in Stockholm, Sweden in 1819 March 1986 (18). In this meeting, the IUCH Constitution was signed and the IUCH established. The interim Board elected at the Constitutional Assembly consisted of Bent Harvald (Denmark), President, Brian Postl (Canada) Vice President, and Ted Mala (USA) Secretary General and Treasurer. As the official meeting of the fledgling International Union for Circumpolar, the next international gathering was entitled a Congress, instead of a Symposium, per se. The 7th ICCH (ICCH) was held in Umea, Sweden, 812 June 1987 (19). During the 7th ICCH, the first IUCH General Assembly was convened on 11 June 1987. The General Assembly elected Jens Peder Hart Hansen, the first President of the IUCH. By 24 September 1987 the IUCH had been further organized with Bylaws. The 4 adhering bodies to the new IUCH were joined by a representative from the Scientific Committee for Antarctic Research. Recognition of circumpolar movement commitment The Canadian Society for Circumpolar Health, with the help of a Donner Foundation (20) grant and government support, struck medals in honour of J. A. Hildes, a revered former Canadian health researcher and a mentor to many. Dr. Hildes was originally from Manitoba and died in 1984. The medals were to be given to an outstanding representative from each of the 4 adhering bodies of the IUCH. These are considered the highest award in circumpolar health. The first Hildes medals were awarded in Umea in 1987. The 8th ICCH was held in Whitehorse, Canada, from 21 to 25 May 1990. Approximately 750 delegates from 20 countries attended (21). In November 1991, the Nordic Society for Arctic Medicine was founded at an inaugural meeting in Stockholm, Sweden. The 9th ICCH was held in Reykjavik, Iceland, from 20 to 25 June 1993. One main topic was the transfer of responsibility for health and health services to indigenous peoples (22). The 10th ICCH was held in Anchorage, Alaska, from 19 to 24 May 1996 and was the first ICCH to utilize the Internet for online dissemination of Congress information (23). At the end of 1996, the Nordic Council of Ministers decided to discontinue funding for the NCAMR. This event signalled the end of the close governmental support for the circumpolar health movement, hence a need for

strategies to continue the work of improving the health status in the circumpolar region through partnerships with other funding agencies. The 11th ICCH was held in Harstad, Norway, from 4 to 9 June 2000. The Millennium Congress included Internet access. The 11th ICCH utilized the Internet for modified online and facsimile Congress registration (24).

Information era speeds up: circumpolar health keeps up While the use of the Internet for ICCH registration opened up new horizons, the hardbound Proceedings publication process continued to be expensive and time consuming. Despite a dedicated local editorial staff, some Proceedings were not available for 2 years after the Congress. The publication of the 11th ICCH Proceedings began a major shift to more rapid access to the Proceedings material with a goal of publishing within 12 months of the Congress. The 12th ICCH was held in Nuuk, Greenland from 11 to 14 September 2003 with preCongress meetings on 810 September 2003 was the first to offer complete Internet registration access. The 12th ICCH Proceedings continued the trend towards rapid dissemination of the material by publishing the Proceedings in the International Journal of Circumpolar Health within 12 months of the Congress (25). The publication of the 12th ICCH Proceedings moved the dissemination of circumpolar health information one major step further by publishing the actual Proceedings full articles, both online and hard copy, for example not just an online Table of Contents. This was the first Proceedings that included ‘‘Study Design’’ in the manuscript’s Abstract along with Objectives, Methods and Results, and Conclusions. The designation of ‘‘Study Design’’ required the researcher and editor to analyze and document the exact nature of the epidemiologic investigation. At the 12th ICCH in Nuuk, Greenland, Bjerregaard, Young and Curtis provided documentation of a shift of focus from biologic to the sociology of health (26). The 12th ICCH Proceedings were being published just as the International Journal for Circumpolar Health initially negotiated to incorporate new academic publishing partners by joining the University of Alaska, Anchorage, University of Oulu and the University of Manitoba. Other academic publishing partners and sponsoring members then joined the IUCH, and the Nordic Society for Arctic Medicine to form the International Association of Circumpolar Health Publishers (IACHP). International Association of Circumpolar Health Publishers The IACHP was established in 2004 to oversee and financially support the International Journal for Circumpolar Health. The journal has been in existence since 1972, initially under the name of Nordic Council for Arctic Medical Research Reports but later under different


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more idiomatic names. IACHP consisted of 8 major and some contributing institutions [universities, societies, International Network for Circumpolar Health Research (INCHR)] with a strong commitment to supporting circumpolar health research and in particular the dissemination of research results.

Mentoring future circumpolar health leaders The 12th ICCH began the tradition of formally recognizing the talents of emerging scientists, researchers and health workers. In the tradition of the simple, but persuasive mentoring methods that were the hallmark of Jens Peder Hart Hansen, the IUCH Council awarded the Jens Peder Hart Hansen Fellow Award to emerging scientists, researchers and health workers (27). These awards are funded by a tithe from the ICCH registrants that is deposited in a managed fund to insure future capacity to move the awards to a self-supporting status. International Network for Circumpolar Health Research The International Network for Circumpolar Health Research (INCHR) was established in 2005 as an offshoot of the IUCH Population Health/Surveys Working Group. Following several years of informal discussions among Working Group health researchers, it was decided to more formally approach those activities. In February 2004, at a symposium at the University of Toronto entitled ‘‘Populations in Transition: The Health of Circumpolar Indigenous People,’’ an agreement was signed to form an international organization devoted specifically to circumpolar health research, recognizing the need for continuing networking in the interlude between the international circumpolar health congresses. The activities of INCHR were funded by a 5-year Canadian ‘‘Team Grant’’ that allowed the organization to conduct various activities without levying membership fees. Rounding the corner The 13th International Congress on Circumpolar Health (ICCH 13) was held in Novosibirsk, Russia, from 12 to 16 June 2006. The Congress theme was ‘‘The North*The Peace Zone.’’ ICCH 13 carried on the tradition of realtime web-based dissemination of the conference abstracts. All of the ICCH 13 Proceedings full-length articles were peer reviewed and indexed in the major scientific clearinghouses within 1 year of ICCH 13, both online and in hard copy (28). The 14th International Congress on Circumpolar Health (ICCH 14) was held in Yellowknife, Canada, from 11 to 16 July 2009. While the conference abstracts were available online in real-time, the organizers chose not to peer review and hence not scientifically index the ICCH 14 Proceedings and instead publish the Proceed-

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ings as a Circumpolar Health Supplement with the IJCH 16 months after ICCH 14 (29). The 15th ICCH 15 was held in Fairbanks, Alaska, from 5 to 10 August 2012. The conference abstracts were available online in real-time, with the Plenary Sessions live streamed on the Internet. The ICCH 15 Proceedings were sponsored by the Arctic Human Health Initiative (AHHI) and are on course to be published within 11 months of ICCH 15 (30). Based on the experience of ICCH 14, the ICCH 15 allowed both a peer track and a non-peer-review track. Both modalities will be available both online and in hard copy, while the peer-review manuscripts will also be indexed in the major scientific clearinghouses. As of this writing, the 16th International Congress on Circumpolar Health, Focus on Future Health and Wellbeing, is scheduled to take place in Oulu, Finland on 713 June 2015.

The Circumpolar Health Research Network (CirchNet) At the time of the ICCH 15 in August 2012, the IACHP and the INCHR were in discussions about how to most effectively accomplish their common goals. At the time of this writing, the 2 groups merged to form the Circumpolar Health Research Network (CirchNet) later in 2012 with the coming together of 2 international circumpolar health organizations the INCHR and the IACHP. This new association aims to: (a) promote cooperation and collaboration among health researchers engaged in research in the circumpolar region; (b) facilitate the exchange, communication and dissemination of research results and other health data; (c) support the training and development of researchers in circumpolar health; (d) publish the International Journal of Circumpolar Health and other scholarly publications.

The successes There has been a trend towards more rapid dissemination of scientific content, more analytic documentation of epidemiologic study design and wider dissemination of scientific content. Key benchmarks include: Indexing of manuscripts All but two of the Proceedings since ICCH 7 have been indexed in Index Medicus. Peer review Five of the last 6 Proceedings utilized a full peer-review evaluation, for example ICCH 10, 11, 12, 13 and 15. Online publication The ICCH 12, 13 and 15 published full-length peerreviewed Proceedings manuscripts online within 12



months of the Congress. ICCH 14 was published online 16 months after the ICCH. The Health Sciences Information Service of the University of Alaska Anchorage’s Consortium Library has obtained copyright permission to scan and archive all the prior ICCH Proceedings online at www.arctichealth.org. The ICCH13 was the first ICCH to publish the ICCH abstracts electronically on the Internet in real-time, for example published online during the ICCH (31).

Scientific method The ICCH Proceedings included an attempt to delineate manuscript content with structured abstracts including the designation of ‘‘Study Design’’. The latter requires the researcher and editor to analyze and document the exact nature of the epidemiologic investigation. Economy of scale Since ICCH 11 and ICCH 12, the local organizing committees have tried to utilize existing resources at the International Journal of Circumpolar Health with its ‘‘economy of scale’’ and editorial expertise. These trends will allow local ICCH organizing committees to concentrate on the Congress, Scientific Program, logistics and follow-up. If this trend continues, this also may lead to more uniformity in scientific and editorial practices. On the other hand, at this time the original scientific methods still rely largely on descriptive reviews with rare international collaborative studies, hence the scientific impact factor ratings need to increase to continue to be sustainable. The circumpolar health movement completes a full circle In many respects, the circumpolar movement has completed its first full circle. In 1957, the Nordic Council appointed a committee for arctic medical research, which began a process that culminated with the NCAMR Report. In that same year, the world celebrated the

International Geophysical Year. The recent inception of the INCHR will now promote researcher-to-researcher relationships to increase collaboration, support research training at all levels and strengthen the health information system. It is hoped that the INCHR will help improve the scientific methods used by increasing the number of international cohort studies that apply similar methodologies across circumpolar borders. Only 2 such studies were reported in the ICCH 12 Proceedings (32,33). The Arctic Council’s AHHI added ‘‘human health’’ emphasis to the IPY, just as the circumpolar movement enters a new phase of collaboration. The AHHI advanced the joint research agenda of the Arctic Council (34). The IPY 20072008 was an intense, internationally coordinated campaign of research that initiated a new era in polar science. IPY 20072008 included research in both Polar Regions and recognized the strong links these regions have with the rest of the globe. AHHI educated and involved the public, and helped train the next generation of engineers, scientists and leaders. The 2010 Arctic Human Health Initiative Circumpolar Health Supplement detailed human health in the Arctic, circumpolar cooperation on Arctic human health, human health and the Arctic Council, the IPY human health proposals, expansion of networks, research proposals, and their outreach education and communication proposals (1).

Should we spend the IUCH account down to zero? Some IUCH Council members have suggested that the IUCH carry a zero balance in its account by expending all of the funds on special projects and research. Interestingly, this has nearly happened just by inertia alone (Fig. 1). This question is not merely conjecture because if the steep downward nature of the current slope continues, the IUCH may not have funding to provide for basic operations in the foreseeable future. A zero- balance scenario

Fig. 1. International Union of Circumpolar Health Funds 19962010 in USD. Citation: Int J Circumpolar Health 2013, 72: 21608 - http://dx.doi.org/10.3402/ijch.v72i0.21608

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would occur if an outgoing Council saw the IUCH funds reach a near-zero nadir in conjunction with an ICCH, that is did not leave enough funds for future Hildes awards and the requisite official Council travel expenses for the next ICCH. In that scenario, the funding would lurch from ICCH to ICCH based on individual adhering body’s ability to provide start-up capital before ICCH registration fees materialized. A zero-balance system would only favour those adhering bodies with a large membership to capitalize ICCHs. As it is, the current system is more egalitarian, as it allows each adhering body an equal voice in requesting an ICCH in their region. To better understand the IUCH budget, one must appreciate that there is a cyclic nature to the highs and lows of the IUCH funds. After the governmental support of the European members ended, the ICCHs on the North American continent have been the most heavily subscribed. As the IUCH funding is based on a tithe from the ICCH registrants, the highest account balances occur after the Canadian and American Society’s ICCHs due to simple demography. Other IUCH budget factors include: funding of IUCH Council President’s travel; funding of At-Large members travel, and special projects. The IUCH budget performs best if: ICCHs are held in geographic venues with easy airline access; the Council President and At-Large members have alternative funding to attend Council meetings or other official activities, and if special projects are funded by outside grants. The IUCH account reached its zenith in 1998 and is nearing its nadir now, despite a large ICCH in Canada in 2009, in part due to the anticipated funding of special supplement if the International Journal of Circumpolar health to highlight the work of the IUCH Working Groups (Fig. 1). The IUCH should explore forming a foundation to provide on-going support of the Hildes Award. Initially, this foundation could be funded through grants and donations, but could also be supplemented with an ICCH tithe system of on-going support, like the Jens Peder Hart Hansen Award. One could easily conjecture that if the original Donner Foundation grant was placed in a similar financial instrument, that the Hildes award would be selfsustaining at this time.

Recommendations for the future (a) Encourage alternative funding strategies 1) Develop a foundation to support on-going expenses, for example Hildes awards. 2) Explore venues to finance Council President and At-Large members travel costs. 3) Seek grants to fund special projects, for example special supplements in the IJCH. (b) Online publication of the ICCH Proceedings within 6 months. This should be possible with careful preICCH planning. With further refinement, the ICCH

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Proceedings could be published online in decreasing intervals. (c) The use of the existing expertise of the International Journal for Circumpolar Health should continue and increase. (d) Encourage a shift from uni-dimensional descriptive studies to 1) coordinated circumpolar cohort studies; 2) interventional studies; 3) randomized controlled trials.

What the IUCH is, and what it is not? (a) The key strengths of the IUCH are (35): 1) elected representatives from the national circumpolar societies from all of the Arctic countries; 2) focused working groups in a variety of fields; 3) observer status on the Arctic Council; 4) The ICCH every 3 years; 5) strong ties to the International Journal of Circumpolar Health enabling IUCH Working Group members to publish findings, presented at the ICCH meetings; 6) information sharing via the IUCH website and the ICCH; 7) mentoring scholarships and recognition of achievements. (b) The IUCH council is currently addressing a number of challenges, including: 1) limited finances (Fig. 1); 2) irregular attendance of the IUCH representative at the AC meetings; 3) lack of regular annual reporting by all WGs to the IUCH; 4) loss of information/knowledge from past IUCH councils.

What IUCH is not . . . yet One of the persistent issues is whether the IUCH could be a primary funder of circumpolar health research. Given the current financial system whereby the IUCH funds are largely dependent on a tithe based on the number of registered attendees at the ICCHs, the IUCH funds have consistently diminished since the era of government funding (Fig. 1). To that end, the ASCH volunteered to increase their tithe from the ICCH 15 by 50% to improve the IUCH’s flagging financial situation. If the 3 strategies outlined earlier to provide longterm funding are adopted, then the IUCH could explore funding alternatives to serve as a research clearinghouse. The IUCH would be very well positioned to assure that circumpolar health emphasizes multinational collaborations/cohort studies, and that those studies are not duplicative.



Another question that has persistently arisen is ‘‘should the IUCH be an individual membership organization?’’ This type of system would gather dues from individual members, rather than being based on a system of adhering bodies. Demographically at this time, there are proportionally more Canadians in a position to pay such individual dues, compared to other adhering bodies, and they could find their views better represented by numbers alone. However, if the metric was based on the size of the adhering body’s base organization, and not its ability to pay individual dues per se, then the Siberian Branch of the Russian Academy of Medical Sciences (AMS-SB) would have the largest number of votes. In the short term, it may be more expeditious to pursue institutional funding from governmental or nongovernmental non-profit agencies, private entities or profit-making ventures. There is IUCH precedent for employing a Secretariat whose main purpose was fundraising, though unfortunately in each of the 2 cases the experiment was not successful. We must better understand that history, so as not to repeat it. There have also been discussions of re-organizing several of the current circumpolar organizations, for example IUCH, Circumpolar Health Research Network (CirchNet), and so on (36). One initial step may be for the IUCH to welcome CirchNet in as a voting member with 1 vote on the IUCH Council similar to the 1 vote that the Scientific Committee for Antarctic Research (SCAR) is entitled to. Finally, the IUCH should consider forming a foundation to provide on-going support of the Hildes Award. Initially, this could be funded through grants and donations, but could be supplemented with a tithe system of on-going support, like the Jens Peder Hart Hansen Award, to become self-sufficient.

Summary The circumpolar region may now be warming due to a global climate change, but the issues of cold, darkness, isolation, distance, adaptation and permafrost still need study to help human inhabitants adapt. The circumpolar movement began as a vision of a few talented individuals who took the time and energy to pursue international collaboration and cooperation to further increase the knowledge and pursuit of improved circumpolar health. One can hope that the knowledge generated by the circumpolar movement will help stem the onslaught of chronic illnesses associated with socio-economic effects and cultural change. If one takes a broad view of what affects our health as human inhabitants of the circumpolar regions, we are profoundly impacted by both the physical and social environments. Many in the circumpolar health movement believe that those 2 aspects are not mutually exclusive. Indeed, in circumpolar regions, those 2 aspects may be even more interdependent than

elsewhere on this planet. We should celebrate the successes that have been accomplished in circumpolar health to date including the more rapid and wider dissemination of scientific content. We should now strive for increasingly rapid dissemination of scientific content, more rigorous scientific methods and increased international collaborative studies. The IUCH should explore alternative funding solutions, for example a foundation to support the Hildes Award; obtain grants for special projects; and create a fund-raising secretariat. The IUCH must continue adapting to change, both political and environmental, while it provides the big umbrella to improve circumpolar health collaboration.

Conflict of interest and funding The author has not received any funding or benefits from industry or elsewhere to conduct this study.

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26. Bjerregaard P, Young TK, Curtis T. 35 years of ICCH: evolution or stagnation of circumpolar health research? Int J Circumpolar Health. 2004;63(Suppl 2):239. 27. Anonymous. Jens Peder Hart Hansen Awards. Int J Circumpolar Health. 2003;62:4449. 28. Murphy N, Krivoschekov S, editors. Circumpolar health 2006. Proceedings of the 13th International Congress on Circumpolar Health, Novosibirsk, Russia, June 1216, 2006. p. 1275. 29. Chatwood S, Orr P, Ika¨heimo T, editors. Proceedings of the 14th International Congress on Circumpolar Health. Int J Circumpolar Health. 2010; November (Suppl 7):1596. 30. Murphy N, Parkinson A, editors. Proceedings of the 15th International Congress on Circumpolar Health. Int J Circumpolar Health. 2013;72(Suppl 1). doi: 10.3402/ijch.v72i0.22447. 31. Murphy N. ICCH 13 the gateway to human health in the international polar year: summary of the congress held in Novosibirsk, Russia. Int J Circumpolar Health. 2006;65: 2924. 32. Dudarev AA, Konoplev AV, Sandanger TM, Vlasov SV, Miretsky GI, Samsonov DP, et al. Blood concentrations of persistent toxic substances in the indigenous communities of the Russian Arctic. In: Leppaluoto J, editor. Circumpolar health 2003: proceedings of the 12th International Congress on Circumpolar Health September 1014, 2003, Nuuk, Greenland. Int J Circumpolar Health. 2004;63(Suppl):17982. 33. Schnohr C, Pedersen JM, Alcoń MCG, Curtis T, Bjerregaard P. Trends in the dietary patterns and prevalence of obesity among Greenlandic school children. In: Leppaluoto J, editor. Circumpolar health 2003: proceedings of the 12th International Congress on Circumpolar Health. September 1014, 2003, Nuuk, Greenland. Int J Circumpolar Health. 2004;63 (Suppl):2614. 34. Parkinson A, Orr P, Murphy N. International Polar Year Arctic human health initiative. Int J Circumpolar Health. 2006;65:2849. 35. Michael B. The International Union for Circumpolar Health an important actor in circumpolar health. Int J Circumpolar Health. 2011;70:35. 36. Chatwood S, Parkinson A, Johnson R. Circumpolar health collaborations: a description of players and call for further dialogue to enhance synergies. Int J Circumpolar Health. 2011;70:57683. *Neil J. Murphy 4320 Diplomacy Drive PCC-WH Anchorage, AK 99508 USA Tel: 907 729 3154 Fax: 907 729 3170 Email: [email protected]


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Circumpolar health what is next? Kue Young* Dalla Lana School of Public Health, University of Toronto, Toronto, Canada

t is a tremendous honour for me to be speaking at a plenary session on the first day of this 15th International Congress of Circumpolar Health. Unlike the previous speaker, the youthful Dr. Neil Murphy, who gets to speak about the past, this old-timer has been tasked to talk about the future. First, a couple of personal notes: I first attended ICCH-6, held in Anchorage, Alaska, in 1984. I can proudly claim that I have not missed a single congress since. I therefore feel that it is my duty to caution members of the audience who are here for the first time. The ICCH is habit forming, and it can actually alter lives! I will, of course, not talk totally about the future, since my guess is as good as yours, and who will hold me responsible years from now when my prediction turns out not to be true? What I will talk about are:

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(a) (b) (c) (d) (e) (f)

Who are circumpolar peoples? How has our population changed? Do we enjoy the same health? Why are we unequal? What are our health care challenges? and What can the circumpolar health ‘‘community’’ do?

The circumpolar world We have all seen a map of the world as seen from somewhere atop the North Pole (Fig. 1). You will be surprised that many people, including those who are knowledgeable in global health affairs, have never seen the world presented like that. Perhaps the Arctic Ocean in the 21st century is like the Mediterranean in the 1st century. For the sake of argument, let us just say there are 8 Member States of the Arctic Council, and within these, there are some 27 political-administrative regions, the boundaries of which are often in flux, and some may disappear altogether from time to time. Within these 27 regions, there are some 10 million people, belonging to diverse cultures and speaking many tongues. There are indigenous people, and there are migrants both old and new. The North today is very much part of the global economy. It may be remote, but it is no longer isolated. We tend to know the North in our own backyard best, and often forget that there are other ‘‘Norths.’’ That is why we have ‘‘circumpolar’’ this and ‘‘circumpolar’’ that.

If we do not get anything out of these triennial jamborees, we should at the very least recognise the tremendous diversity in many ways, not just across circumpolar regions but also within regions. Here are some generalisations that you may hear from people speaking about ‘‘their North’’: (a) ‘‘The North is numerically small relative to the country as a whole’’ well, yes and no. Regions such as Alaska and the northern territories of Canada account for less than 0.5% of the population of the United States and of Canada, respectively, while Greenland and Faroe Island’s population is each only about 1% that of Denmark. In contrast, across Eurasia, the population of the northern regions of Norway, Sweden, Finland and Russia range from 5 to 12% of their respective total national population. (b) ‘‘The North is nothing but a vast expanse of nothing’’ it is true that there are very few people occupying a gigantic landmass. For example, Nunavut has only 0.02 persons per km2. However, Faroe Islands’ population density is 35 persons per km2. You will be surprised to know that most northerners actually live in cities. Within regions, the proportion of the population that live in cities may account from 20 to 70% of the total regional population. While there are no cities having more than 25,000 inhabitants in northern Canada or Greenland, there are large ones in the 50,000 to 150,000 range in northern Scandinavia, and even larger cities can be found in the Russian North, for example, Arkhangelsk ( 350,000). Alaska’s Anchorage (280,000) is of course a northern metropolis. (c) ‘‘The North is all about indigenous people’’ this is largely true for Nunavut and Greenland, where over 85% of the population are Inuit. In the Northwest Territories, indigenous people account for about 50% of the population; in the Yukon it is 25%, and in Alaska, 20%. In Russia, indigenous people are a sizable minority in several of the autonomous regions: Chukotka (30%), Koryakia (40%), Taymyr (25%) and Nenets (20%). Accurate figures are not available in Scandinavia, but the Sami are likely less


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Fig. 1. Circumpolar countries and regions.

than 10% of the population of the northernmost counties, with the possible exception of Finnmark in Norway, which may be higher. Regardless of their numbers or share of the total regional population, it is true that indigenous people experience substantial health disparities relative to other populations in most regions. (d) ‘‘The North is poor’’ if we use the per capita Gross Domestic Product as the yardstick, then most northern regions are not much worse off than their countries as a whole, and the per capita GDP of some regions are actually several times higher, especially those regions where there are large-scale oil and gas developments, for example, the KhantyMansi, Yamalo-Nenets and Nenets autonomous regions in Russia. However, how the rich proceeds from natural resources development are distributed and how they actually benefit Northerners is another matter. Within the North, where individual-level socioeconomic indicators are available, indigenous people tend to fare worse than non-indigenous people in most regions. (e) ‘‘The North is stagnating’’ when referring to the rise and fall of population, some regions are experiencing significant population growth, especially Nunavut,

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Alaska, Iceland, Khanty-Mansi, Northwest Territories and Yamalo-Nenets, due to a variety of reasons, including high fertility and/or high in-migration spurred on by economic development. At the other end are most of the northern regions of Russia (except the 2 mentioned above), which have suffered substantial de-population, with some regions such as Magadan having lost as much as half of their population over a 20-year period.

Health disparities The people in the circumpolar North do not all enjoy the same health. There are substantial disparities among countries and regions, and within regions. If we compare circumpolar countries, and using something such as the United Nations Human Development Index, then it is clear that Russia lags far behind the others, ranking 65th in the world in 2010, whereas the other Arctic States are all within the top 20. Circumpolar regions basically fall into 4 groups: (a) The Nordic countries these do best in every health indicator, and there is generally little difference between north and south, or between indigenous and non-indigenous people;


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(b) Alaska, Yukon and the Northwest Territories their health status is comparable to, or even better than, the national average of the United States and Canada; however, within these regions, there are substantial disparities between indigenous and nonindigenous people; (c) Greenland and Nunavut with over 85% of the population indigenous, there is a wide gap in health status between these regions and Denmark and Canada; and (d) the Russian Arctic while the regions in the European North tend to fare better than those in Siberia, in almost any health indicator, the Arctic regions of Russia tend to occur at the lower end of the spectrum. What are some of the health problems where disparities among regions are the greatest? Looking at the period 20052009, infant mortality rate ranges from 2 per 1,000 live births in Iceland to 28 in Koryakia. The mean national incidence rates for tuberculosis in the Nordic countries, Canada and the United States are less than 10/100,000. The rates for Greenland (130) and Nunavut (150) are more than 10 times higher. While the mean rate of the northern Russian regions is about 80, among them is Koryakia, with a rate as high as 450. Suicide among youth is particularly rampant in Greenland and Nunavut, a phenomenon observed also among Alaska Natives. ‘‘Social determinants of health’’ is currently the dominant explanatory model for health disparities. To a large extent it is also applicable in the Arctic. Ecological studies confirm the association between socioeconomic indicators such as education and health outcomes, and life expectancy and infectious disease incidence. A social gradient exists not just for death and diseases, but also for behaviors such as smoking and alcohol abuse. Large population surveys across the Arctic, most notably the Survey of Living Conditions in the Arctic (SLiCA), provide some of this evidence. Moreover one needs to look beyond individual differences to explain variation at the population level. Historical, contextual and policy differences likely play a significant role in accounting for health disparities across circumpolar regions. Here is a ripe area not just for empirical research, but also for sound theoretical understanding and fresh insights.

Health care challenges Many of us are involved in circumpolar health in a variety of roles, as researchers, health care providers, administrators and policy makers. Health care may not solve all our problems, but it is amenable to innovations and improvements, and thus deserves our attention whatever our professional designation may be. First, another reality check. As I have already mentioned, the North is highly urbanised. In the large urban

centres, health care would not be very different from the southern parts of the country. It is not this ‘‘sector’’ where serious problems of access and quality arise, although issues of access and quality are national problems also. Thus a discussion of the challenges to health care in the North is really about that segment of the population living in remote, scattered, small villages and hamlets, exposed to the harsh environment and its adverse effects on infrastructure, facilities, equipment, and the quality of life and well-being of health care staff and patients. It is not just an issue of insufficient resources, since on a per capita level, many northern regions have health expenditures that are among the highest in the world. Whether they are ‘‘enough’’ or represent ‘‘value for money’’ is of course another issue, for which there are no easy answers. What is unclear is whether northern health care will soon reach, or has already reached, the point of unsustainability. Here is another research gap that remains to be filled. Strategies are needed for health human resources development. Northern regions can build on many proud achievements Alaska’s health aides, Canada’s primary care nurses, and Russia’s feldschers and mobile medical teams come to mind and should freely borrow best practices from one another. Multidisciplinary teams are a noble concept, that is, strong in rhetoric but instances where they are truly practised are few and far between. Much progress has also been made in bringing training of health professionals to the North. I have come full circle to recognising the importance of technology innovations in remote health care. If developing countries can ‘‘leapfrog’’ technologies, surely Arctic countries, which are among the world’s technologically most advanced countries, can develop and deploy technologies that can overcome existing barriers to equitable and effective health care? Just as mobile telephones have thrived in countries with crumbling conventional telecommunication infrastructure, why not use robots to replace the revolving door of short-term visiting health providers and free from the vagaries of travel due to uncooperative weather? Again, the North has taken the lead in testing telehealth technologies, but the time has surely come when we move beyond pilot studies to system change. Although ‘‘knowledge translation’’ (KT) has acquired the status of a buzz word, it is safe to say that only a minority of devotees know what it really means and understand its intricacies. We would all agree that it is something that is needed. Researchers are rightly exhorted to engage in KT to justify the public money that has been showered upon them. Equally important, policy makers also need to recognise the importance of ‘‘evidence’’, which is something that health researchers can provide.


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Looking ahead

Disclaimer

A look at the congress program reassures me that circumpolar health is healthy and sound, and that at each congress there is a new crop of young recruits, with a few old-timers hanging around purportedly to provide ‘‘mentorship.’’ The circumpolar health ‘‘community’’ needs to be active in different fronts. Among Arctic scientists the biologists, geologists, climatologists, etc. health scientists are gaining increasing recognition, in part due to the prominence of health research in the activities of the International Polar Year. The momentum needs to be sustained. On another front, we need to keep on top of the political agenda of national and regional governments, and not just agencies involved in health care. At the international level, the Arctic Council is an important forum, and the creation of its Arctic Human Health Expert Group is a step in the right direction. Perhaps it is a sign that circumpolar health has grown that we now have multiple organisations, consisting of more or less the same people, competing for the same small pool of resources. Circumpolar health is more than just the congress, which creates excitement once every 3 years, only to dissipate in the intervening interval. There needs to be on-going engagement of the ‘‘community.’’ There is tremendous opportunity for strong and sustained, rather than sporadic and intermittent, collaboration at the institutional and individual levels. Let us take advantage of this congress to network, engage in friendly debate and reach consensus.

Please note this article bears some resemblance to what was actually said in my plenary presentation at the 15th International Congress of Circumpolar Health.

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Further readings This paper is unadorned and thus uninterrupted by footnotes and references. For further exploration of some of the ideas presented here, please consult: 1. Young TK, Bjerregaard P, eds. Health transitions in Arctic populations. Toronto: University of Toronto Press; 2008. 2. Young TK, Rawat R, Dallmann W, Chatwood S, Bjerregaard P, eds. Circumpolar health atlas. Toronto: University of Toronto Press; 2012. 3. Chatwood S, Bjerregaard P, Young TK. Global health circumpolar perspectives. Am J Public Health. 2012;102:12469. For statistical data, please visit the Circumpolar Health Observatory http://circhob.circumpolarhealth.org

*Kue Young Email: [email protected]


PLENARY SESSIONS æ

Childhood exposure to domestic violence: implications and opportunities for circumpolar health Linda Chamberlain* Founding Director, Alaska Family Violence Prevention Project

Magnitude of the problem Domestic violence (DV), defined as a repetitive pattern of abusive behaviors within an intimate relationship, is an all too common occurrence in the circumpolar world that leads to predictable physical, behavioral, cognitive and social problems for children living in violent households. In Alaska, 7.2% of mothers with a 3-year-old child reported physical abuse by an intimate partner (1). In Denmark, 8.5% of girls and 5.8% of boys have witnessed physical abuse (2). While these data are limited to witnessing physical abuse, DV also includes sexual and psychological abuse and other controlling behaviors. Children can be exposed to DV in many different ways, including hearing the violence and threats, feeling the hurt and blame, be asked by the abusive parent to report on the other parent, coming home to the aftermath of violence and living in fear. All forms of childhood exposure to DV are potentially toxic stressors that can disrupt healthy brain development and interfere with a child’s ability to learn. Children growing up in homes with DV are more likely to have a wide range of problems, including internalising and externalising behaviors (2).

Promising practices The good news is that we know more about how to help children exposed to DV than ever before. Healing starts with healthy relationships. Dual advocacy, working together with victimised mothers and their children, is a key characteristic of evidence-based interventions for children exposed to DV and other trauma. Exposure to DV compromises children’s socio-emotional skills. Teaching children self-regulation, empathy, how to express emotions and other core social skills are central features of effective interventions with children exposed to DV. Because children mirror what they learn at home, they need to start learning what healthy relationships look like early in life to reduce the risk of inter-generational family violence. There is a broad selection of evidence-based and research-informed interventions for children exposed to DV that builds on 2 or more decades of field experience.

These interventions have been implemented in a wide range of settings, including DV shelters, schools, after-school programmes, homeless shelters, mental health clinics and other community-based agencies. One example of a brief, evidence-based intervention for children exposed to DV is Kids’ Club and Mom’s Empowerment (3). This 10-week intervention works with mothers and their children who participate in separate, small group sessions and also receive individual counselling. The parenting programme is designed to support and empower mothers to recognise how DV can impact their children’s development while learning traumainformed parenting skills. The group sessions provide a safe setting for mothers, who are often isolated through their victimisation, to discuss fear and worries about parenting and to build social connections with other mothers. In the children’s groups, the initial focus is on helping children to feel safe, to establish trust and to be able to find healthy, non-destructive ways to express their emotions about their experiences. Building on this foundation, children learn that the violence is not their fault. Using an interactive, skills-based approach, children learn strategies for managing their emotions and self-regulation, conflict and resolution skills, and how to have healthy relationships with peers and adults.

Evidence-based intervention with mothers and children A randomised, controlled trial of Kids’ Club and Mom’s Empowerment was conducted with sequential assignment to three conditions: child-only intervention, child-plus mother intervention and a wait-list comparison group (3). The study population comprised boys and girls, 6 through 12 years of age, and their mothers. Seventeen per cent of the mothers were currently living with their abusive partner and 68% had some contact with, but were not living with, their abusive partners, at the start of the study. Women had been in an abusive relationship for an average of 10 years. The child-plus-mother intervention was the most effective in reducing symptoms among children exposed to DV. From baseline to 8-month follow-up after the intervention,


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there was a reduction of 77% for internalising behaviors and 79% for externalising behaviors among children in the child-plus-mother intervention group. Further analysis of the data from this trial indicated that children’s disclosures of their experiences with DV in the group sessions were associated with significant improvement in their behavioral adjustment problems and attitudes and beliefs about the acceptability of violence. Kid’s Club and Mom’s Empowerment is an affordable intervention that demonstrates the effectiveness of dual advocacy working with mothers and children together. The programme, which originated in the United States, has been implemented in Canada and Sweden. The training manual is available in English and Swedish. Other interventions for children exposed to DV include trauma-focused cognitive behavioral therapy (TF-CBT), which has been evaluated with Native American and Alaska Native children, and Connections and Breaking the Cycle, an innovative intervention for mothers with substance abuse problems and their children that was developed in Canada. Profiles of these interventions and other best practices can be found at www. promisingfutureswithoutviolence.org.

Future directions and resources A growing body of research on the impact of toxic stress on children’s neurodevelopment and the effect of adverse childhood experiences over the lifespan demonstrate how DV is connected to many leading circumpolar health concerns, including mental health problems, substance abuse, injuries and suicide, prenatal alcohol exposure, maternal and child health, and risk of obesity. These connections make a strong case for routine assessment and universal education in all public health settings. The Alaska Native Tribal Health Consortium and the Alaska Family Violence Prevention Project are working in partnership with Futures Without Violence to adapt an evidence-based strategy, called the safety card approach, to facilitate screening and education with clients. The safety card, which includes self-administered questions about DV, provides information about healthy relationships, how abuse can impact health and parenting skills, and information about safety planning and resources. Samples of existing safety cards, which can also be used by service providers to facilitate direct face-to-face

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assessment with patients, can be found under resources for the health care setting at www.futureswithoutviolence. org. Public health professionals need state-of-the-art training on DV that is relevant to the work they do. Making the Connection: Domestic Violence and Public Health is a free toolkit that is designed for public health service providers (www.futureswithoutviolence.org). The toolkit, which includes a PowerPoint presentation with speaker notes and an extensive bibliography, has chapters dedicated to specific areas of public health, including women’s health, reproductive health, child and adolescent health, behavioral health, perinatal programmes, injury prevention and sexually transmitted diseases. As we learn more about the long-term effects of childhood exposure to violence and the inter-generational transmission of trauma, there is more emphasis on educating parents and communities about early brain development, resiliency factors and the potential for healing. The Institute for Safe Families (www.instituteforsafefamilies. org) had developed the Amazing Brain booklet series to educate parents about early brain development, the effects of trauma and positive parenting strategies to help traumatised children. The Alaska Family Violence Prevention Project is collaborating with the Institute for Safe Families to expand the series to address the impact of adverse childhood experiences on parenting and children and also publish a booklet called ‘‘It’s Never Too Late’’ to help adult survivors of childhood trauma.

References 1. State of Alaskaa. Childhood Understanding Behaviors Survey (CUBS) [cited 2012 Oct 10]. Available from: http://dps.alaska. gov/CDSA/dashboard. 2. Helweg-Larsen K, Frederiksen ML, Larsen HB. Violence, a risk factor for poor mental health in adolescence: a Danish nationally representative youth survey. Scand J Public Health. 2011;39:84956. 3. Graham-Bermann SA, Banyard V, Lynch S, DeVoe ER. Community-based intervention for children exposed to intimate partner violence: an efficacy trial. J Consult Clin Psychol. 2007;75:199209. *Linda Chamberlain Email: [email protected]


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Developing healthy communities: understanding maternal child health determinants in Nunavut Laura Arbour* University of British Columbia, Medical Genetics, Island Medical Program, Victoria, Canada

lthough most infants are born healthy there, Nunavut leads the country for adverse early child health outcomes such as infant mortality rates (1,2), birth defects (3), prematurity and low birth weight (46). Nunavut is Canada’s largest jurisdictional landmass, with 26 remote (fly-in) communities and 33,000 inhabitants, of which 85% self-identify as Inuit (7). An estimated 800 infants are born in Nunavut each year, with 9095% of those being born to Inuit women (6,8). The territorial capital Iqaluit hosts the Qikiqtani Regional Hospital; however, residents of the Qikiqtani region receive tertiary medical care in Ottawa, Ontario, whilst residents of Kivalliq depend upon acute medical care delivered in Manitoba, and individuals residing in Kitikmeot depend upon both the Northwest Territories and Alberta. Approximately 45% of the 800 infants born each year to Nunavut residents are born out of territory (7). The birth rate in Nunavut is twice the national average, resulting in a pyramid shaped age gradient where 60% of the population is below 25 years of age. The median and average income of Inuit in Nunavut ($15,866 and $25,030, respectively) is 6070% of the Canadian average and median incomes ($25,615 and $35,498, respectively) (9), although the cost of living is 1.63 times higher (7). Since all communities are ‘‘fly-in’’, transportation costs need to be factored into health care budgets. To transfer a pregnant woman to southern Canada for a premature delivery at greater than $30,000 per transfer results in an estimated cost of more than $2.5 million just for transport alone for the nearly 100 women (12%) who will have a premature birth per year. The 20082013 Nunavut Public Health Strategy, ‘‘Developing Healthy Communities’’, first priority is Healthy Children and Families with primary goals to increase the incidence of healthy birth outcomes and the number of children reaching age-appropriate milestones, and to improve food security for all families (10). On a medevac to Pond Inlet from Iqaluit in 1993, I became aware of a high rate of congenital heart defects in the Inuit of Nunavut. Dr. Marc Paquet, a paediatric

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cardiologist, told the story of how he had made regular visits from McGill University to Iqaluit for 20 years and had noted the higher than expected number of children with congenital heart defects. He presented data from his clinic visits at the 9th ICCH in Reykjavik, Iceland, and encouraged me to explore the possible reasons. As Dr. Paquet had observed, our chart review of 2567 live births to Inuit mothers between 1989 and 1994, in Nunavut and Nunavik (Arctic Quebec), demonstrated the rate of birth defects was nearly twice that of a wellestablished birth defect registry in Canada (OR 1.93, 95% CI: 1.72.3) and the rate of septal defects as per the ICD9 745 category was particularly increased (OR 4.18, 95% CI: 3.25.4) (3). This led to further studies, and the question as to whether genetic factors and/or a diet low in dietary folate might contribute, consistent with other studies suggesting that folic acid supplementation or fortification could reduce heart defects along with neural tube defects, the primary target (1113). We met with 60 Inuit women with children with heart defects from 8 communities in Nunavut and 58 mothers of children without birth defects. Medical, pregnancy and family history questionnaires were administered along with blood drawing for DNA extraction, red blood cell folate (RBCF), serum cobalamin and plasma homocysteine. Although it was well known at that time that multivitamins are important in the prevention of birth defects if taken periconceptionally, no Inuit mothers (n118) reported taking multivitamins during the periconceptional period for their pregnancies, or at the time of the interview. Furthermore, there was no difference in pregnancies exposed to alcohol (25% between cases and controls) and no difference in cigarette smoking (80%). There were no differences observed in red cell folate levels, cobalamin and homocysteine, although about half of the women had RBC levels that were below ‘‘target’’ and considered to be protective for birth defects (900 nmol/L) (14). Genetic markers of folate uptake and metabolism revealing statistical differences between mothers of cases and mothers of controls


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included RFC-1 (80A 0G) and MTHFR (677C 0T), which have both been previously implicated in studies of heart defects and other birth defects (1517). With a continued focus on folic acid and prevention of birth defects, local research advisory members suggested a re-assessment to reflect possible changes in birth defect rates following folic acid fortification to grain products which had occurred in all of Canada by 1998. A repeat chart review, carried out in the Qikiqtaaluk region of Nunavut on 2018 births to Inuit mothers from 2000 to 2006, revealed an over-all decrease in birth defects of approximately 20% (70/1,000 live births vs. 86/1,000, OR: 0.8, 95% CI: 0.641.0), including a decrease in heart defects. However, the odds of having a septal heart defect for an Inuit mother, compared to the birth defect registry in Alberta, was still 3-fold (18.3/1,000 vs. 6.2/1,000, OR: 3.0, 95% CI: 2.24.2) (18). The same chart review was used to better understand the maternal risk factors for major malformations in Nunavut. Dr. Candace Sy, a resident in the UBC Aboriginal Residency Program, presented her work at the ICCH 14 in Yellowknife in 2009, demonstrating that premature birth and alcohol use in pregnancy, conferred the highest statistical association with all major malformations (n 77) (OR 6.4, 95% CI: 3.212.8 and OR: 2.22, 95% CI 1.04.9) compared to the next 4 births without major malformations from the same community (n307). None of the other maternal factors including any smoking, prenatal vitamin use, or documented marijuana use were statistically associated, although the latter approached significance (OR: 1.6, CI: 0.93.2); although limited by size, a sub-analysis of the same maternal factors in association with only heart defects revealed preterm birth as having a significant positive association with heart malformations (excluding PDA) (OR: 11.59; 95% CI: 3.340.5). Again, documented marijuana use approached statistical significance (OR: 2.45, 95% CI: 0.946.7), as did alcohol use (OR: 2.77, 95% CI: 0.98.8), but all other maternal factors were not significant (19). In summary, we conclude that the higher rate of heart defects in Nunavut likely has a multifactorial etiology. Nutritional factors such as folate, genetic factors and risk factors that predispose to prematurity all likely influence the rate. A focus on prevention by recognizing and addressing modifiable risk factors needs to be considered. With this in mind, during the development of the Inuit Health Survey, which was conducted in 20072008, Grace Egeland and I discussed the merit of including a focus on folate for women of childbearing years. Kait Duncan, a UBC medical student, worked with us to analyse the RBCF levels for the 249 non-pregnant Inuit women of childbearing age (1939 years) included in the survey. Several variables that might influence outcomes were also evaluated, including region of residence, cigar-

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ette use, food security and body mass index (BMI). As discussed at ICCH 15 (Fairbanks), those in the lowest quartile for RBCF were difficult to distinguish from those in the highest quartiles, although there was a trend towards more food insecurity, lower BMIs and waist circumference and increased cigarette use for those in the lowest quartile (20). In reviewing the outcomes of our studies in general, we were particularly struck with the risk for major malformations, especially heart malformations when an Inuit infant is born prematurely. This association has been previously reported suggesting that similar underlying mechanisms may contribute to both (21). To understand more comprehensively the possible contributors to adverse pregnancy outcomes including preterm birth and low birth weight, we used a sub-population from the chart review described above on 2018 live births between 2000 and 2006 to understand better the possible determinants. Our study focused on smoking, although previous studies in the Baffin region had suggested no apparent association of smoking with adverse birth outcomes (6). It is well established that about 80% of Inuit women in Nunavut smoke during pregnancy; however, relatively few of those smoke more that 10 cigarettes per day. Kate Mehaffey, a resident in the UBC Aboriginal Residency Program, addressed this question for us. Only those charts from 1 January 2003 and 1 January 2006 were utilized (1,022 births) since smoking status was recorded at the first prenatal visit on 90% (n918) of prenatal charts, and of those smoking, 80% of charts also included number of cigarettes smoked per day. Birth weight at term, prematurity, low birth weight (LBW), small for gestational age (SGA), and substance use were assessed by category. The categories included: those not smoking at their first prenatal visit (n 175); smoking 14 cigarettes per day (n 215), 59 (n 196), 10 (n 181); and smoking but no quantity recorded (n151); and total smokers (n 743) (81%) (5). Our results revealed that for women not smoking, or smoking less than 5 cigarettes per day, pregnancy outcomes were consistently better than average outcomes in the rest of Canada. Smokers of more than 10 cigarettes daily had 6times the rate of LBW infants, a nearly 4-fold increased risk of SGA births, and double the rate of premature births compared with non-smokers. Smokers (of any amount) also had inferior perinatal outcomes, with almost a 4-fold increased risk of LBW, a 2-fold increased risk of SGA and significantly decreased average birth weights compared with the non-smoking group. The reasons for the increased risk in this group are likely multifactorial (e.g. nutritional factors, associated exposures, etc.), and not due to smoking alone; therefore, more information was needed to understand the complex interactions.


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Since that time, we have corroborated Mehaffey’s results, with a larger study from the BC Perinatal Health Program (BCPHP). Anders Erickson, a PhD student at the University of Victoria, carried out the analysis on 233,891 records of singleton births in BC from 2000 to 2006 with available smoking status (22). A significant dose-dependent increase in risk was observed for the following adverse birth outcomes: SGA, term low birth weight and intra-uterine growth restriction. Results from the pp-odds model indicate heavy smokers were more likely to have not graduated high school: AOR 3.80 (95% CI: 3.414.25); be a single parent: 2.27 (95% CI: 2.142.42); have indication of drug or alcohol use: 7.65 (95% CI: 6.998.39) and 2.20 (95% CI: 1.882.59), respectively; attend fewer than 4 prenatal care visits: 1.39 (95% CI: 1.231.58); and be multiparous: 1.59 (95% CI: 1.511.68) compared to light, moderate and nonsmokers combined. Our studies suggest that recognizing and supporting those women who report smoking greater than 10 cigarettes per day could be a first step in reducing adverse pregnancy outcomes. High rates of infant mortality in Nunavut have been an on-going concern in Nunavut, as in other Canadian Inuit populations (23), with sudden infant death syndrome (SIDS) and infection, including respiratory, leading the causes for death. SIDS is a diagnosis of exclusion where the cause of death remains unexplained after a thorough investigation, including a complete autopsy, examination of the death scene and review of clinical history. Sudden Unexpected Death in Infancy (SUDI) is a term sometimes used that includes unexpected infant deaths with other risk factors present, such as a minor illness or risk factors for asphyxia. Sorcha Collins, a PhD student at UBC, set out to understand the determinants of infant mortality in Nunavut. In conjunction with the Chief Coroner and the Chief Medical Officer of Health, Collins reviewed 117 cases of infant deaths experienced by Inuit women residing in Nunavut. The well-known Triple Risk Hypothesis (24) suggests an interaction of: 1) a critical developmental period of time; 2) underlying inherent vulnerability; and 3) exogenous stressor (environmental factors) as an underlying mechanism for SIDS. Placing infants to sleep on their backs (supine) has substantially reduced SIDS worldwide, apparently over-riding inherent risk factors and reducing the risk of asphyxia (25,26). Results from surveys of Nunavut mothers suggest that only 3846% of mothers place their infants to sleep on their backs, compared to 77% for the rest of Canada (27,28). While it is controversial whether bed-sharing (sharing a sleep surface with an infant) is a risk factor itself, bed-sharing is associated with increased risk for SIDS when combined with other risk factors, including non-supine sleep position, bed-sharing with a non-caregiver and bedsharing with a parent/caregiver who smokes or has

impaired arousal (29,30). Genetic factors such as a predisposition to arrhythmia, or fatty acid oxidation disorders are said to account for underlying inherent vulnerability in 619% of cases. Of relevance to the North, a common genetic variant for a fatty acid disorder possibly predisposing to hypoglycaemia has been considered as a potential risk factor for both infant mortality caused by SIDS and respiratory illness (31,32). Multiple risk factors influence the high rate of infant mortality in Nunavut consistent with the Triple Risk Hypothesis. Of the 117 cases reviewed, sudden unexpected death was the responsible diagnosis in 48% of cases and infection accounted for another 21%, both rates significantly higher than for Canada (20032007). Of sudden unexpected death cases with information on sleep position (n42) and bed-sharing (n 47), 29 (69%) were sleeping non-supine and 33 (70%) were bed-sharing. Of those bed-sharing, 23 (70%) had 2 or more additional risk factors present, usually non-supine sleep position. CPT1A P479L homozygosity, which has been previously associated with infant mortality in Alaska Native and British Columbia First Nations populations, was associated with unexpected infant death (SIDS/SUDI, infection) throughout Nunavut (OR 3.43, 95% CI: 1.30 11.47); however, the association was less clear when analyzed according to region. In summary, we found that unexpected infant deaths comprise the majority of infant deaths in Nunavut. Although the CPT1A P479L variant was associated with unexpected infant death in Nunavut as a whole, the association was less apparent when population stratification was considered. Strategies to promote safe sleep practices and further understand other potential risk factors for infant mortality (P479L variant, respiratory illness) are underway with local partners. This work, led by Gwen Healey and Sharon Edmunds-Potvin of Qaujigiartiit Health Research Centre and Nunavut Tunngavik Inc. Iqaluit, NU, along with Sorcha Collins of UBC, is underway, and preliminary data were presented at ICCH 15 (33). The information above largely provided by chart reviews, small studies and surveys reveals just the tip of the iceberg when considering the determinants of a maternalchild in Nunavut. A sustainable, comprehensive, dynamic, public health surveillance system is needed. A combined University of British Columbia/Nunavut Public Health Strategy effort led by Dr. Geraldine Osborne, Nunavut’s Chief Medical Officer of Health in partnership with Nunavut Tunngavik Inc. and Qaujigiartiit Health Research Centre saw the initiation of a comprehensive maternalchild health surveillance system (from 16 weeks gestation to age 5), ‘‘The Nutaqqavut Health Information System’’. A diverse group of professional and lay stakeholders were brought together initially to determine local interest. Following this, a series of small working groups were held to decide


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on potential prenatal, perinatal and early child health variables, to be documented. Over 100 Nunavut participants have now had some role in the development of the system which has been initiated. Pre-existing standard prenatal forms and well-child assessment forms have been modified to include ‘‘Nunavut specific’’ variables of nutrition, breastfeeding, food and domestic security, exposures in pregnancy, birth defects, respiratory illness, chronic diseases of childhood and developmental support needs. This comprehensive maternalchild health information system has been developed with the extensive input of health care providers and stakeholders, utilizing community and public health systems already in place. Careful assessment of local needs has contributed to database development, privacy protection, potential data utilization for health promotion and plans for dissemination of findings. It is hoped that the potential of this user-friendly surveillance system will be realised and adaptable to other community and public health systems to improve the understanding of Aboriginal maternalchild health determinants (34). In conclusion, most women in Nunavut have positive birth outcomes, but a number of underlying determinants acting alone and in combination such as food insecurity, sub-optimal folate levels, high smoking rates, lack of adoption of supine sleep position and genetic factors, all likely influence birth outcomes. Efforts to further understand and reduce rates of prematurity, birth defects and infant mortality are under way. More information is needed to understand the complex interactions important in the determinants of early Inuit health. The Nutaqqavut Health Information System has now been implemented and priority studies are now being planned.

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References 1. Statistics Canada. Table 102-0507 infant mortality, by age group, Canada, provinces and territories, annual, CANSIM (database). 2012. [cited 2013 Jun 25]. Available from: http:// www5.statcan.gc.ca/cansim/a26?langeng&retrLangeng&id 1020507&paSer&pattern&stByVal1&p11&p2-1&tab ModedataTable&csid 2. Collins SA, Surmala P, Osborne G, Greenberg C, Bathory LW, Edmunds-Potvin S, et al. Causes and risk factors for infant mortality in Nunavut, Canada 19992011. BMC Pediatr. 2012;12:190. 3. Arbour L, Gilpin C, Millor-Roy V, Platt R, Pekeles G, Egeland GM, et al. Heart defects and other malformations in the Inuit in Canada: a baseline study. Int J Circumpolar Health. 2004; 63:25166. 4. Canadian Institute for Health Information. To early, too small: a profile of small babies across Canada. Ottawa, ON: CIHI; 2009. 5. Mehaffey K, Higginson A, Cowan J, Osborne GM, Arbour LT. Maternal smoking at first prenatal visit as a marker of risk for adverse pregnancy outcomes in the Qikiqtaaluk (Baffin) Region. Rural Remote Health. 2010;10:1484. 6. Muggah E, Way D, Muirhead M, Baskerville B. Preterm delivery among Inuit women in the Baffin Region of the

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Canadian Arctic. Int J Circumpolar Health. 2004;63(Suppl 2): 2427. Nunavut Bureau of Statistics. Nunavut quick facts and population estimates. Iqaluit, NU: Government of Nunavut; 20082013; 2013. Statistics Canada. Aboriginal peoples in Canada in 2006: Inuit, Me´tis and First Nations, 2006 census: findings. Catalogue no. 97-558-XIE. 2008. [cited 2013 Jun 25]. Available from: http://www12.statcan.ca/census-recensement/2006/as-sa/97-558/ index-eng.cfm?CFID78991&CFTOKEN71134813 Statistics Canada. 2006 census of population: Aboriginal ancestry, area of residence, age groups, sex and selected demographic, cultural, labour force, educational and income characteristics (227A), for the total population of Canada, provinces and territories, 2006 Census Catalogue no. 97-564XCB2006001. Ottawa, ON: Minister Responsible for Statistics Canada; 2008. Government of Nunavut Department of Health and Social Services. Developing healthy communities: a public health strategy for Nunavut. Iqaluit, NU: Government of Nunavut; 20082013; 2008. Botto LD, Mulinare J, Erickson JD. Occurrence of congenital heart defects in relation to maternal mulitivitamin use. Am J Epidemiol. 2000;151:87884. Czeizel AE. Periconceptional folic acid containing multivitamin supplementation. Eur J Obstet Gynecol Reprod Biol. 1998;78:15161. Shaw GM, Lammer EJ, Wasserman CR, O’Malley CD, Tolarova MM. Risks of orofacial clefts in children born to women using multivitamins containing folic acid periconceptionally. Lancet. 1995;346:3936. Arbour L, Rupps R, MacDonald S, Forth M, Yang J, Nowdluk M, et al. Congenital heart defects in Canadian Inuit: is more folic acid making a difference? Alaska Med. 2007; 49(Suppl 2):1636. Pei L, Zhu H, Zhu J, Ren A, Finnell RH, Li Z. Genetic variation of infant reduced folate carrier (A80G) and risk of orofacial defects and congenital heart defects in China. Ann Epidemiol. 2006;16:3526. Van Beynum IM, Kapusta L, den Heijer M, Vermeulen SHHM, Kouwenberg M, Danie¨ls O, et al. Maternal MTHFR 677C T is a risk factor for congenital heart defects: effect modification by periconceptional folate supplementation. Eur Heart J. 2006;27:9817. Botto LD, Yang Q. 5, 10-Methylenetetrahydrofolate reductase gene variants and congenital anomalies: a HuGE review. Am J Epidemiol. 2000;151:86277. Cowan J, Osborne G, Sobol I, Arbour L. Then and now: birth defects on Baffin Island revisited after folic acid fortification [abstract]. Winnipeg, MB: Canadian Public Health Association. Annual Meeting Public Health in Canada. Strengthening Connection. [cited 2009 Jun 8]. Available from: http://www. cpha.ca/en/conferences/archives/conf2009.aspx Sy C, Cowan J, Sobol I, Osborne G, Arbour L. Chart review analysis of maternal factors and major malformations on Baffin Island 20002005 [abstract]. Circumpolar Heal Suppl. 2012;7:1912. Duncan K, Arbour L, Egeland GM. Factors influencing red blood cell folate levels of Canadian Inuit women of child bearing years: results from the 20072008 Inuit health survey [Abstract]. Proceedings of 15th International Congress on Circumpolar Health (ICCH) 15. 2012. 77 p. Tanner K, Sabrine N, Wren C. Cardiovascular malformations among preterm infants. Pediatrics. 2005;116:e8338. Erickson AC, Arbour LT. Heavy smoking during pregnancy as a marker for other risk factors of adverse birth outcomes: a


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23.

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population-based study in British Columbia, Canada. BMC Public Health. 2012;12:102. Luo ZC, Senecal S, Simonet F, Guimond E, Penney C, Wilkins R. Birth outcomes in the Inuit-inhabited areas of Canada. CMAJ. 2010;182:23542. Guntheroth WG, Spiers PS. The triple risk hypotheses in sudden infant death syndrome. Pediatrics. 2002;110:e64. Kinney HC, Thach BT. The sudden infant death syndrome. N Engl J Med. 2009;361:795805. Canadian Paediatric Society. Recommendations for safe sleeping environments for infants and children. Paediatr Child Health. 2004;9:65963. Asuri S, Ryan A, Arbour L. Looking to the future: report on prevention of SIDS in Inuit regions. Vancouver: Inuit Tapiriit Kanatami (ITK), University of British Columbia (UBC); 2011 Jul. Report No. 1. Public Health Agency of Canada. What mothers say: the Canadian maternity experiences survey. Ottawa, ON; 2009. [cited 2013 Jun 25]. Available from: http://www.phac-aspc.gc. ca/rhs-ssg/survey-eng.php Blair PS, Platt MW, Smith IJ, Fleming PJ. Sudden infant death syndrome and sleeping position in pre-term and low birth weight infants: an opportunity for targeted intervention. Arch Dis Child. 2006;91:1016.

30. Horsley T, Clifford T, Barrowman N, Bennett S, Yazdi F, Sampson M, et al. Benefits and harms associated with the practice of bed sharing: a systematic review. Arch Pediatr Adolesc Med. 2007;161:23745. 31. Collins SA, Sinclair G, McIntosh S, Bamforth F, Thompson R, Sobol I, et al. Carnitine palmitoyltransferase 1A (CPT1A) P479L prevalence in live newborns in Yukon, Northwest Territories, and Nunavut. Mol Genet Metab. 2010;101:2004. 32. Gessner BD, Gillingham MB, Birch S, Wood T, Koeller DM. Evidence for an association between infant mortality and a carnitine palmitoyltransferase 1A genetic variant. Pediatrics. 2010;126:94551. 33. Healey G, Edmunds-Potvin S, Collins S, Osborne G, Arbour L. Gathering community perspectives on infant sleep practices in Nunavut with an aim to prevent SIDS. Fairbanks, AK; 2012. 34. Lauson S, McIntosh S, Obed N, Healey G, Asuri S, Osborne G, et al. The development of a comprehensive maternal-child health surveillance system for Nunavut-Nutaqqavut (our children). Int J Circumpolar Health. 2011;70:36372. *Laura Arbour Email: [email protected]


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Arctic health and research: challenges and opportunities Fran Ulmer* US Arctic Research Commission, Anchorage, AK, USA

he health of the Arctic region and the health of its people are highly interconnected; research can serve both. My remarks at ICCH 2012 addressed the characteristics, trends, challenges and opportunities emerging in the Arctic, and how they relate to health research. The Arctic is a cold, ice-dominated region with extreme weather; it is an ocean bordered by 8 countries. Approximately 4 million Arctic inhabitants live in small, remote communities where accessibility, communication, and infrastructure are limited, and where resilient, indigenous cultures rely on the natural resources of the region. The Arctic is undergoing rapid and profound change, environmentally, as well as socially and economically. Icedependent species and cultures that are organized around the harvest and consumption of the marine mammals, birds, fish and other resources are being stressed by the rapid retreat of sea ice, the thawing permafrost, more unpredictable weather and by other changes. The uncertainty of food sources, evolving subsistence strategies, threats to the safety of hunters, damage to infrastructure, contamination from airborne chemicals, and emerging issues associated with urbanization and industrialization are all presenting challenges to the health and well-being of Arctic people. As development opportunities arise, enabled by sea ice retreat, international interests are focusing on a wide range of potential investments, such as oil and gas, minerals, fishing, shipping, construction, and tourism, and many of which were previously considered unrealistic. Arctic people are both attracted to and alarmed by these developments. What’s key is the manner in which they are pursued. Approaches could provide significant benefits, or could undermine environmental and cultural well-being. How can research help in such decisions? Clearly, the wisest planning, preparation and response to these changes will be those that are informed by the best available information. To assure the least amount of negative impacts and the greatest local benefit to the people of the region, Arctic nations and others must invest

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in relevant research, and consider the results, in order to support responsible and sustainable development. The US Arctic Research Commission (USARC) was created by Congress to: (a) develop, recommend and assist in implementing a national Arctic research policy; (b) facilitate Arctic research cooperation among Federal, State and local governments; (c) review federal Arctic research programs and recommend improvements; and (d) recommend improved methods for data sharing among Arctic research entities. USARC provides recommendations about how best to focus the research resources in the US to address pressing Arctic issues. Our recent Goals Report (issued January 2012) identifies 5 priorities: Arctic human health, environmental change, civil infrastructure, natural resource assessment and earth science, and indigenous languages and culture. Arctic human health research includes a wide range of diverse topics, but all have a core concern: the well-being of Arctic people. And the health of a region’s people is highly correlated with the health of their environment. Health does not occur in a vacuum. This brings to mind the words of recently departed Dr. Barry Commoner, who eloquently summed up the issue as, ‘‘Everything is connected to everything else. Everything must go somewhere. Nature knows best. There is no such thing as a free lunch.’’ Arctic human health issues are described in the ‘‘Arctic Human Development Report,’’ the first comprehensive and pan-Arctic evaluation of human wellbeing. This report, mandated under the Arctic Council’s 2002 Ministerial Declaration as a priority project, describes the well-being of Arctic residents as a combination of the following: material success, health, education, ties to nature, cultural continuity and fate control. Research, especially that which incorporates traditional knowledge, investigates living conditions in the Arctic and promotes health and well-being, which is strongly supported by the USARC. The Commission continues to address issues such as assuring food security, providing clean water in an affordable, sustainable and


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healthful manner in remote villages, and addressing the extremely high rates of suicide that unfortunately are common in many areas in the High North. USARC has hosted a series of conversations about the challenge of behavioral and mental health, which resulted in a report published by the Journal of Circumpolar Health in 2010, available here: http://www.arctic. gov/publications/behavioral_health.html USARC is also helping stakeholders develop innovative and sustainable solutions to village water and sanitation challenges. Leadership from the USARC helped create the ‘‘Alaska Rural Water and Sanitation Workgroup,’’ which is the only forum in Alaska where representatives from the Federal, State, Alaska Native and tribal entities, non-governmental organizations and academia convene to discuss issues related to water and sanitation challenges specific to rural communities, and to work together to improve health outcomes for rural residents. In support of such efforts, Alaska’s Governor and Legislature allocated $1 M in the 2012 budget for a water and sanitation technology development program. Some of USARC’s specific Arctic health recommendations include: a. Additional research in basic biomedical and behavioral health, and increased funding to do so. b. Expanded community health analyses, including environmental health interactions. c. Recurring assessments of intervention efforts to evaluate effectiveness.

The recommendations and results from these efforts will hopefully translate into policy improvements and initiatives that will benefit the people of the Arctic. This is a continuing process that benefits from dialogue among researchers, health care practitioners, community leaders and the people of the Arctic. In order to stay current and achieve our mission, USARC works to keep up to date on health research issues, projects, results and best practices in sharing information. We invite recommendations and ask that comments and suggestions be made at www. arctic.gov. At that location, you will also find the Arctic Update, a daily email newsletter about Arctic research, conferences and general international news. You may subscribe or find archives with useful background information.

Suggested readings 1. Levintova M, Zapol WI, Engmann N, editors. Behavioral and Mental Health Research in the Arctic: strategy setting meeting proceedings. [cited 2013 Jun 25]. Available from: http://www. arctic.gov/publications/behavioral_health.html 2. Gessner BD. Lack of piped water and sewage services is associated with pediatric lower respiratory tract infection in Alaska. J Pediatr. 2008;152:66670. 3. Wenger JD, Zulz T, Bruden D, Singleton R, Bruce MG, Bulkow L, et al. Invasive pneumococcal disease in Alaskan children: impact of the seven-valent pneumococcal conjugate vaccine and the role of water supply. Pediatr Infect Dis J. 2010;29:2516. *Fran Ulmer Email: [email protected]


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Vulnerable populations: health of humans and animals in a changed landscape Birgitta Evenga˚rd* Division of Infectious Diseases, Department of Clinical Microbiology, UMEA˚ University Hospital, Umea, Sweden

he climate is changing. There have always been natural variations in temperature and CO2 concentrations, as demonstrated in samples from the Antarctic ice sheet dating back some 800,000 years. But something has affected the stable era, the Holocene that the globe has been in for the past 10,000 years. Repeated measures from recent years show that for the past 200 years, the rise in global temperature and in CO2 levels occurred at a speed not previously observed. In 1769, the patent for the steam engine was registered marking the start of the Industrial Revolution and since then activities of man have accelerated the increase in CO2. This new era has been called the Anthropocene, to reflect man’s impact on the earth’s ecosystems. The changes are noticed mostly in the north of the globe and current predictive models all agree that changes will affect the northern hemisphere first. Up to now, real-time measures underestimate the changes predicted by modelling. Changes have occurred at a higher rate than first predicted. Because of the complexity of the drivers of ecosystem change and because we yet do not have all the tools needed to analyse the complex changes taking place, it is important to realize that we do not know much of what the outcome of climate change will be. Reports from the International Panel on Climate Change (IPCC) point to an increase in extreme weather events. The Greenland ice sheet has decreased by 70 metres in 5 years, and if it continues at this rate, it will have an impact on the level of the oceans. Consequently, we have come to understand that the globe is more fragile than robust. And those changes in eco-systems will affect us as humans, a species among others on the globe. The Arctic and its people are facing drastic change. Given the close dependence on natural resources, global climate change (and globalization) is expected to have immediate and significant consequences for Arctic populations and local communities. Arctic societies and cultures are faced with multiple stressors and challenges related to the on-going and

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combined effects of environmental processes (impacts of climate change); cultural developments (erosion of indigenous languages); economic changes (the emergence of narrowly based mixed economies); industrial developments (the growing role of multinational corporations engaged in the extraction of natural resources); and political changes (the devolution of political authority). The distant and once economically unviable resources of the far north will be linked to global markets more closely than ever before, playing an increasingly important role in the world economy. They constitute a new frontier of investment and industrialization. Indigenous peoples live in closer contact with nature than others and have valuable knowledge of on-going biophysical and ecological processes. The rest of the world can learn a lot of adaptive strategies from them and from studies on what is happening due to climate change to the eco-systems in the north. The changes include a higher level of mental ill-health and the health consequences of a change of diet to a more western way of eating (including a much higher intake of processed foods), causing overweight, type 2 diabetes and an increase in cardiovascular diseases. For example, mortality rates for Alaska Natives exceed that of other citizens in the United States. a. Life expectancy 64.9 years vs. 76.7 years for the United States b. Infant mortality 8.7/1,000 vs. 7.2/1,000 for the United States c. Unintentional injury mortality 3.3 times US rate d. Suicide 4.2 times rate for all races in the United States e. Cancer mortality is 1.5 times all races in the United States f. Higher rates of some infectious diseases Life expectancy of the indigenous populations also of northern Canada, Greenland and the northern Russian Federation is lower than that of the respective national


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populations. Infant mortality remains higher than respective populations of the US, northern Canada, Greenland and northern Russian Federation. In fact, for some conditions, the mortality has increased among indigenous peoples as living conditions have changed, from a lower baseline compared to the other population to levels exceeding the population. The exception is the Saami population. In the Nordic countries, the Saami have the same health standard as the general population but a slightly higher suicide rate among male reindeer herders. Mortality rates for heart disease and cancer were once lower among the indigenous populations of the US, Canada and northern European countries, but are now similar to their national rates. Today, climate change is considered to be a humanrights issue, not least through some work by activists like Sheila Watt-Cloutier. Food security is a central concern and an important example. Food security requires that all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active healthy life. However, with the advent of climate change, climatic conditions and seasonal timetables will change in ways that affect food yields. Other more specific problems will result. Today, 70% of Inuit pre-schoolers in households in northern Canada are rated as food insecure. For example, underground ice cellars traditionally used to store whale meat frozen all year round no longer function safely due to thawing of the permafrost. Such climate-related changes in long-standing customs and ways of living ultimately lead to stress, mental disorders and suicides. Animals that were previously hunted have disappeared or are contaminated so recommendations include not eating them as frequently as before. Water security means having access to water of good quality. Without access to food and water of good quality, health is threatened and living conditions are impaired. Data reported in this issue show that, in Alaska in areas with declining access to water, there is an increase in respiratory and skin infections resulting in more cases of hospitalisation. A surveillance of the quality of food and water, and of access to them, is of particular importance in the Arctic, especially now that in addition to longer standing and more localised environmental problems, the climate is changing so rapidly. In many communities in the north, the buildings stand on permafrost. Loss of this support will result in damage to water intake systems and pipes and may result in contamination of community water supplies, and damage to water and sanitation infrastructures and distribution systems forcing communities to rely more on untreated (or traditional) water sources. This is already resulting in increase in clinic visits and hospitalizations for various

‘‘Water washed’’ infectious diseases, those commonly prevented by hand washing such as gastroenteritis, respiratory infections caused by RSV, influenza, skin infections, impetigo, and boils caused by MRSA. With an increase in CO2 in the atmosphere, some trees will produce much more pollen than they do today. This will lead to more allergies among humans and later chronic pulmonary diseases. The increase in precipitation and flooding events will create favourable conditions for mould growth in homes. This indoor exposure may result in an increase in mould-related respiratory disorders and allergies. Environmental risks to health from chemical contaminants in the environment have been of particular concern in the Arctic, due to long-range transportation (atmospheric and ocean transport) from lower latitudes as well as from local sources. Examples of such contaminants are persistent toxic substances, including mercury and lead, and persistent organic pollutants such as polychlorinated biphenyls and pesticides. These hazardous chemicals are of particular concern for the unborn. When flora changes, animals, including mammals, insects and parasites, start adapting very quickly and change boundaries of their habitats in response. With a change in the boundaries of fauna, microorganisms will change boundaries as well. Zoonoses, infections passed to humans from animals, are already the main emerging infections, and this is likely to increase further as habitats for animals change. Warmer temperatures may allow infected host animal species to survive winters in larger numbers, increase in population, and expand their range of habitation, thus increasing the opportunity to pass infections to humans. For example, milder weather and less snow cover may have contributed to a large outbreak of Puumala virus infection in northern Sweden in 2007. The climate-related northern expansion of the boreal forest in Alaska and northern Canada has favoured the steady northward advance of the beaver, potentially extending the range of Giardia, a parasitic infection of beaver that can infect other mammals, including humans who use untreated surface water. Elevated run-off from snow melt and increased precipitation could exacerbate contamination of water supplies with Giardia and Cryptospridium cysts and oocysts. The association between infection and increased precipitation is well recognized. In a recent outbreak in 2 towns in northern Sweden, more than 50,000 residents developed Cryptosporidium-related gastroenteritis after drinking contaminated municipal water following heavy rainfall that overwhelmed water purification systems. Hunters in northern Sweden, for example, have noticed that more ticks are infesting their dogs each year. In Sweden, the number of human cases of tularaemia has increased in the north recently, and Tickborne encephalitis (TBE) is now also occurring over a wider


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Plenary Sessions

region in southern Sweden. Effective surveillance of these changes in the range and seasonality of various infectious diseases, and their health consequences, is needed to minimise future risks for humans and animals. Climate change could exacerbate the potential for the food and/or waterborne transmission of Toxoplasma gondii in the Arctic. The recent discovery of Toxoplasma in polar bears and Arctic foxes in Svalbard underscores the widespread nature of this infection. Another important meat borne parasite in the Arctic is Trichinella, commonly responsible for outbreaks related to the consumption of undercooked bear or walrus meat. The most common species survives freezing. The geographical distribution of cold tolerant verse freeze tolerant Trichinella sp. follows the January isothermal lines (5C for T. native). Thus, shifts in host diversity and environmental temperature could lead to altered distribution. Similarly, warmer temperatures in the Arctic and subArctic regions could support the expansion of the geographical range and populations of foxes and voles, common carriers of Echinococcus multilocularis, the cause of alveolar echinococcus in humans. The Northern strain cystic hydatid disease is caused by Echinococcus granulosus, which maintains a cycle that includes wolves, coyotes, foxes or dogs and caribous. However, several species are also competent hosts for E. granulosus such as moose and deer who may move further north in response to climate change. In Sweden, the incidence of TBE has substantially increased since the mid-1980s. This increase corresponds to a trend of milder winters and an earlier onset of spring, resulting in an increase in the tick population (Ixodes ricinus) that carries the virus responsible for TBE and other potential pathogens. Similar movement of TBE has been documented in northern north-western Russia where Ixodes persulcatus is the predominant vector. This movement corresponds to the estimated climateinduced changes in the I. persulcatus habitat. Whether or not disease in humans is a result of these climate changeinduced alterations in vector range depends on many other factors, such as land-use practices, human behavior (suburban development in wooded areas, outdoor recreational activities, use of insect repellents, etc.) and human population density as well as adequacy of the public health infrastructure.

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Past outbreaks of Anthrax among cattle and reindeer have resulted in more than 13,000 burial grounds in Russia containing the carcasses of infected animals. More than half of these are located on permafrost in Siberia. There is concern that with a warming of the Arctic, melting permafrost in these regions will expose many of these burial sites together with Anthrax and therefore increase the risk of infection in humans. These are also risks for tourists; for example, snow mobile safaris have been moved from lakes to soil in some tourist centres in the Northern Finland. There are also opportunities that will emerge in Arctic regions when resources become more accessible when sea and land ice cover is lost. The image of the Arctic is rapidly changing. It is growing into a dynamic region; a region of interest for many countries, businesses and other stakeholders. But to realize that actions will have an impact on climate and environment is of uttermost importance to mankind, and to realize that the eco-systems are actually part of our society, our place on earth, is fundamental for our survival. Maybe governments are in need of a ‘‘road to Damascus’’ experience to realize how fragile this globe of ours actually is. Let us give them this experience as researchers and as human beings.

Suggested readings 1. Evengard B, McMichael A. Vulnerable populations in the Arctic. Glob Health Action. 2011;4:35. 2. Virginia RA, Yalowitz KS, editors. A new paradigm for Arctic health: challenges and responses to rapid climate, environmental and social change. Workshop Report for May 2325, 2011, Dickey Center for International Understanding and the University of the Arctic Institute for Applied Circumpolar Policy, Dartmouth College, Hanover, NH, USA. 2012. [cited 2013 Jun 25]. Available from: http://dickey.dartmouth.edu/ 3. Parkinson AJ. The international polar year: continuing the arctic human health legacy. Int J Circumpolar Health. 2011; 70:4479. 4. Young OR, Einarsson N. Arctic Human Development Report Akureyri: Stefansson Arctic Institute. 2004. [cited 2013 Jun 25]. Available from: http://hdr.undp.org/en/reports/regionalreports/ other/arctic_2004_en.pdf. *Birgitta Evenga˚rd Email: [email protected]


PLENARY SESSIONS æ

Common problems, uncommon solutions in the Arctic Mead Treadwell* Alaska Lieutenant Governor, Alaska State Capitol Building, Juneau, AK, USA

ll of us here today are part of a small Arctic circle of friends and colleagues. Most of us know each other. Most of us have worked together and we go way back. I remember those first early days of Arctic cooperation with the Arctic Environmental Protection Strategy we looked at things like contaminants, radiation and other environmental health issues that affect us all in the north. Back in those days I had the honour of serving with Ted Mala while I was on Governor Wally Hickel’s Cabinet. Ted was first to tell me of the work of the International Union for Circumpolar Health (IUCH). The state paid attention and got involved. Together with this organization and others, we have built the Arctic neighbourhood. We came together then as we do today, because we recognized that our Arctic neighbourhood had common problems that called for uncommon solutions. And although we have advanced in our knowledge, our science and our efforts, today’s problems that are still common in the Arctic continue to demand uncommon solutions. The challenges are many. We struggle with capacity building for rural health care and mental health care, low population numbers that make epidemiology difficult but underscore the value of cooperation, a lack of vitamin D at high latitude, the possibility of zoonotic diseases and radiation effects at high latitude, where our lives may be affected by space weather or ozone holes. We have all heard detailed reports on alcohol and drug abuse, domestic violence and sexual assault, obesity and diabetes, contaminants in our subsistence foods, childhood trauma, mental health struggles and suicide. As the Arctic becomes more accessible, we face the challenge of changing diets, changing cultures and changing patterns of life, and all of that makes us even more determined to cooperate in solving Arctic health issues. The task of identifying those issues is not the struggle. It is gathering momentum to move forward that proves more difficult. Perhaps the most difficult issue of all is that of suicide. I have personally lost several friends to suicide, my colleagues have lost friends and I would not be surprised if many of you have also been touched by this devastating circumstance. While we recognize that suicide rates in

A

Alaska are higher than in some of our rural villages, we know that smaller populations can be affected in disproportionate ways. We also know that the problem is not just an indigenous problem, but widespread in Alaska and across the Arctic. Our Hispanic, Asian, and Caucasian communities have all also suffered tragedy and loss. The statistics are tragic. At least 175 of our communities have been touched by suicide in the past decade. Earlier in this conference, we hosted a panel on suicide prevention. Besides myself, others who joined the panel included Bill Streur, Alaska Health Commissioner; Dr. Kue Young, University of Toronto; Dave Driscoll, University of Alaska Anchorage; and Barbara Franks, Alaska Native Tribal Health Consortium. We asked ourselves, what are the uncommon solutions that we need in order to end the epidemic of suicide in the North? We looked at it from 2 angles: what can we do in the Arctic Council, and what can we do in health research? And we identified a potential opportunity on the horizon and asked ourselves some difficult questions. The United States will get its turn at the Chairmanship of the Arctic Council in 2015. That gives us the chance to have a substantial say in the agenda, where we focus on Arctic Council efforts, and what we would like to achieve. Quite frankly, tackling the issue of suicide with the other 7 Arctic nations will not likely be a hard sell, as each and every one of them struggles with the issue as well. More challenging is identifying the specific project. What would that project look like? Should it focus on research, the gaps and the lack of coordination? What can we do to make sure that the various clinical methods we have got around the North are tracked and better understood against an academic slide rule? How do we recognize signs, causes and triggers? Our State-wide Suicide Prevention Council is already asking these questions. There is recognition of the interrelatedness of chronic health conditions, domestic violence and sexual assault, violent and non-violent crime, homelessness and suicide. Our state plan on suicide prevention focuses on personal and community action. And while a study by the Institute of Medicine failed to attract the financial support it needed, I will continue


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Plenary Sessions

to argue that medicine is evidence-based. Clinical and academic approaches need to work together. In all areas of health, we cannot forget that we are in this together. I am reminded of John Donne, the 16th century English writer who wrote, No man is an island, Entire of itself. Each is a piece of the continent, A part of the main. If a clod be washed away by the sea, Europe is the less. As well as if a promontory were. As well as if a manor of thine own Or of thine friend’s were. Each man’s death diminishes me, For I am involved in mankind. Therefore, send not to know For whom the bell tolls, It tolls for thee.

We are bonded by our common problems, and we have to work together on uncommon solutions so that our Arctic communities will continue to thrive in the years to come. This is the age the explorers sought for generations. We live in the time of the opening of the northern sea routes, the age of the accessible Arctic Ocean. It is up to

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each and every one of us to make this age one of health and prosperity. Let us be ready; let us go to work.

Further reading 1. Young KT, Bjerregaard P. Health transitions in Arctic populations. Toronto: University of Toronto Press; 2008. 2. Allen J, Levintova M, Mohatt GV. Suicide and alcohol related disorders in the U.S. Arctic: boosting research to address a primary determinant of circumpolar health disparities. Int J Circumpolar Health. 2011;70:47387. 3. Alaska Statewide Suicide Prevention Council. Casting the Net Upstream: Promoting Wellness to Prevent Suicide. SSPC, Jan 2012. Available from: http://dhss.alaska.gov/SuicidePrevention/ Documents/pdfs_sspc/SSPC_2012-2017.pdf 4. Hensel C, Lindley S, Stachelrodt M, Foster D, Ramus SM, Thomas L, et al. The People Awakening Project. Fairbanks: University of Alaska Fairbanks; 2005. Available from: http://dhss. alaska.gov/dbh/Documents/01_External/People%20Awakening% 20Project.pdf 5. Arctic Council’s Sustainable Development Working Group. Hope and resilience: suicide prevention in the Arctic. Conference report. [cited 2009 Nov 78]. Available from: http:// www.sdwg.org/media.php?mid1201 *Mead Treadwell Email: [email protected]


CHAPTER 2. Featured Presentations

Keynote Presenters

FEATURED TOPICS Monday, August 6, 2012 Rebuilding Northern Foodsheds: Sustainable Food Systems, Community Well-Being and Food Security Craig Gerlach, PhD and Philip Loring, PhD, University of Alaska Fairbanks Craig Gerlach and Philip Loring will present a general overview of the current condition of northern food systems, including land use planning, policy barriers and constraints, the long term consequences and impacts of alternative food production strategies, the problems of energy and water management, differential access to food, especially healthy foods in both urban and rural areas, diet-related health problems, and sustainable community health and development. An underlying theme is that sustainable, small scale food production is linked to affordability and access to healthy foods, and that the potential in this area for a new food system intervention strategy to individual and community health has not received enough critical attention. Northern Traditional Health and Healing Ted Mala, MD, MPH, Southcentral Foundation and Marilyn Van Bibber, Arctic Institute of Community-Based Research Northern Indigenous peoples are a key resource in promotion of circumpolar health. The health of indigenous peoples of the circumpolar world has been informed by centuries of traditional knowledge, practice, and connection to environmental resources. Across the north the depth and diversity of indigenous health knowledge has endured as a resource in both addressing complex health conditions and promoting wellbeing in the north. Our Circumpolar health congress is an excellent opportunity to bring together the rigor of scientific findings with indigenous ways of knowing. It is about shared respect, shared knowledge and a coming together with dignity and truly listening to each other.

The Community Health Aide Program is a longstanding and unique health care delivery model for Alaska Native people in remote villages. Health aides are authorized to work under the license of a physician within the guidelines of the Alaska Community Health Aide/ Practitioner Manual which outlines assessment and treatment protocols. Today, there are over 550 Community Health Aides and Community Health Practitioners (CHA/Ps) in 178 rural communities that across Alaska. This presentation will describe this unique care delivery model and how training and certification is being expanded for villagebased dental and behavioral health providers to meet healthcare needs at the local level.

Closing the Gap: Understanding the Dimensions of University-Community Relations Anne George, PhD, University of Northern British Columbia, Travis Holyk, Carrier Sekani Family Services, and Rheanna Robinson, University of British Columbia As research-related gaps between academic and nonacademic communities begin to close, important conversations emerge regarding partnerships between academics, communities, and university research offices. Such partnerships can be fraught with issues relating to the specific needs of each person or organization; on the other hand, considerable benefits come from these collaborative arrangements. Discussions about those benefits and needs are important in community-based research whether the research is initiated by the academic community or by community organizations because both are interested in similar outcomes of evidence-based practice and policy. In spite of research agreements, the differing needs of each organization or person require consideration and understanding. Through a conversation between 3 partners, we will discuss partners’ needs, constraints and ways of solving contentious issues. Tuesday, August 7, 2012

Alaska’s Community Health Aide Program: A Unique Health Care Delivery Model

Nuka Model: Relationships

Victorie Heart, MS, RN, ANTHC and Crystal Stordahl PA-C, MMSc, Tanana Chiefs Conference

Ted Mala, MD, MPH, and Katherine Gottlieb, Southcentral Foundation


It’s

all

About

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Keynote Presenters

Southcentral Foundation’s Nuka System of Care is an Alaska Native customer-owned healthcare system. The system is owned, designed, and managed by Alaska Native people. The result of customer-ownership is improved health outcomes, employee and customer satisfaction, and financial outcomes. Southcentral Foundation’s Nuka system of care has RELATIONSHIPS as an organizing principle. The session will describe the Southcentral Foundation’s Nuka System of Care, and how to improve health outcomes through customerownership and RELATIONSHIPS.

The Arctic Human Health Initiative: Legacy of the International Polar Year

Lots to Lose: Reversing the Obesity Epidemic Ward B. Hurlburt, MD, MPH, Alaska Department of Health and Social Services The medical and economic complications related to overweight and obesity are and for many decades will be the dominant public health problem facing Alaska and the United States. Only very limited resources have been available to date to address this challenge. Nevertheless there are indications of increasing public understanding of the importance of addressing this challenge. A couple of modest success stories related to Alaskan young people will be described of modest success stories related to Alaskan young people will be described.

Alan Parkinson, PhD, US Centers for Disease Control & Prevention Wednesday, August 8, 2012 The Arctic Human Health Initiative (AHHI) is a US led, Sustainable Development Working Group, IPY coordinating project, that aimed to serve as a focal point for human health research, education, outreach, and communication activities during IPY (20072009). The AHHI has been successful in raising the visibility of human health concerns of Arctic residents, and has resulted in increased attention to Arctic health research and prevention and control activities within the circumpolar health community as well as Arctic Council country governments.

Pneumococcal Vaccination Around the World: Challenges and Opportunities

Matt Moore, MD, MPH, US Centers for Disease Control & Prevention Pneumococcal disease is a major cause of morbidity and mortality worldwide, resulting in over 800,000 deaths annually among children B5 years old. Pneumococcal conjugate vaccines, first introduced in 2000, have had dramatic effects on the incidence of pneumococcal disease, not only among young children but also among persons too old to receive the vaccine. At the same time, the incidence of disease caused by some serotypes not included in the vaccine has increased, and these increases have raised concerns about the long-term benefits of conjugate vaccination programs. This presentation will review the global experience with pneumococcal conjugate vaccines,as well as challenges and opportunities in the future.

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Water, Sanitation and Health in the North Troy Ritter, Alaska Native Tribal Health Consortium, and Cheryl Rosa, US Arctic Research Commission There is increasing evidence that in-home water and sewer service is linked to better health. Within Alaska there are significant health disparities that are due to lack of access to in-home water and sewer services. Alaska ranks last among U.S. States for adequate sanitation service; approximately 23% of rural Alaskan households lack in-home water and sewer service. This presentation will describe the efforts of a steering committee of health, water, and sanitation experts to maximize the health benefits of in-home running water and sanitation services in rural Alaska. The speakers will discuss efforts to promote water/sewer construction projects, support operations and maintenance, and to advance research and development to achieve solutions to water and sewer service.

Opportunities for Prevention: HPV vaccines Eileen Dunne, MD, US Centers for Disease Control & Prevention and Anders Koch, MD, Department of Epidemiology Research at Statens Serum Institute The human papillomavirus (HPV) is the cause of cancer of the cervix and several other cancers. HPV vaccine has Circumpolar Health Supplements 2013

Keynote Presenters

recently been introduced and is being used worldwide. This session will provide updates on global HPV vaccine policies, efforts to monitor cases prevented and other issues. The second half of the session will review HPV vaccine activities in the Nordic region. Native People’s Concepts of Health and Illness

Donald A.B. Lindberg MD, National Library of Medicine The Native Voices Exhibition at the National Library of Medicine examines concepts of health and medicine among American Indians, Alaska Natives, and Native Hawaiians. The exhibition includes over 100 interviews of Native persons. Topics discussed concern the individuals, the community, traditions, and health care. A common theme is loss of personal and communal pride and cultural differences as obstacles to sensible health behavior.

An Alaska Native Leader’s Views on Health Research

energy efficient buildings throughout Alaska that prioritize indoor air quality, sanitation, and overall occupant health. Rosie the Robot: Technology

Teamwork

in

Debra Keays-White, Health Canada, Michael Jong, Memorial University, Gail Turner, Nunatsiavut Department of Health and Social Development, Ivar Mendez, Dalhousie University Access to health care is a major challenge in the Circumpolar region. Robotic telemedicine in the remote community of Nain, Labrador, Canada has allowed for greater access and enhanced the delivery of health care. The wireless, mobile robot allowed the physician to be virtually present in Nain. This presentation will allow the audience to see how Rosie the Robot can work from Fairbanks to Nain.

Indigenous Peoples’ in a Changing World

H. Sally Smith, Alaska Native Tribal Health Consortium, Board of Directors; Vice Chairman

Patricia Longley Cochran, Alaska Native Science Commission

This session will focus on the role and value of health research conducted with Alaska Native people. The presentation will include the history of health research and the changes that have taken place in how health research is reviewed, conducted and disseminated in Alaska Native communities. Tribal research review and approval processes will be discussed and examples of how this process works will be shared. Thoughts on current and future research endeavors involving Alaska Native people will be highlighted.

The Arctic may be seen as geographically isolated from the rest of the world, yet the Inuit hunter who falls through the thinning sea ice is connected to melting glaciers in the Andes and the Himalayas, and to the flooding of low-lying and small island states. What happens in foreign capitals and in temperate and tropical countries affects us dramatically in the North. Many of the economic and environmental challenges we face result from activities well to the south of our homelands; and what is happening in the far North will affect what is happening in the South. We are all connected on this planet of ours and the Arctic plays an important role.

Thursday, August 9, 2012 Healthy, Affordable, Sustainable Homes for All Alaskans

Jack He´bert, Cold Climate Housing Research Center This presentation will give an overview of the Cold Climate Housing Research Center in Fairbanks. Their activities involve the design and development of highly Circumpolar Health Supplements 2013

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FEATURED PRESENTATIONS æ

The Arctic Human Health Initiative: a legacy of the International Polar Year 20072009 Alan J. Parkinson* Arctic Investigations Program, Centres for Disease Control and Prevention, Anchorage, AK, USA

Background. The International Polar Year (IPY) 20072008 represented a unique opportunity to further stimulate cooperation and coordination on Arctic health research and increase the awareness and visibility of Arctic regions. The Arctic Human Health Initiative (AHHI) was a US-led Arctic Council IPY coordinating project that aimed to build and expand on existing International Union for Circumpolar Health (IUCH) and Arctic Council human health interests. The project aimed to link researchers with potential international collaborators and to serve as a focal point for human health research, education, outreach and communication activities during the IPY. The progress of projects conducted as part of this initiative up until the end of the Arctic Council Swedish chairmanship in May 2013 is summarized in this report. Design. The overall goals of the AHHI was to increase awareness and visibility of human health concerns of Arctic peoples, foster human health research, and promote health strategies that will improve health and wellbeing of all Arctic residents. Proposed activities to be recognized through the initiative included: expanding research networks that will enhance surveillance and monitoring of health issues of concern to Arctic peoples, and increase collaboration and coordination of human health research; fostering research that will examine the health impact of anthropogenic pollution, rapid modernization and economic development, climate variability, infectious and chronic diseases, intentional and unintentional injuries, promoting education, outreach and communication that will focus public and political attention on Arctic health issues, using a variety of publications, printed and electronic reports from scientific conferences, symposia and workshops targeting researchers, students, communities and policy makers; promoting the translation of research into health policy and community action including implementation of prevention strategies and health promotion; and promoting synergy and strategic direction of Arctic human health research and health promotion. Results. As of 31 March, 2009, the official end of the IPY, AHHI represented a total of 38 proposals, including 21 individual Expressions of Intent (EoI), and 9 full proposals (FP), submitted to the IPY Joint Committee for review and approval from lead investigators from the US, Canada, Greenland, Norway, Finland, Sweden and the Russian Federation. In addition, there were 10 National Initiatives (NI-projects undertaken during IPY beyond the IPY Joint Committee review process). Individual project details can be viewed at www.arctichealth.org. The AHHI currently monitors the progress of 28 individual active human health projects in the following thematic areas: health network expansion (5 projects), infectious disease research (7 projects), environmental health research (7 projects), behavioral and mental health research (4 projects), and outreach education and communication (5 projects). Conclusions. While some projects have been completed, others will continue well beyond the IPY. The IPY 20072008 represented a unique opportunity to further stimulate cooperation and coordination on Arctic health research and increase the awareness and visibility of Arctic regions. Keywords: International Polar Year; Arctic Health; research; education outreach communication; Arctic Council

he International Polar Year (IPY) was an intensive multidisciplinary program of collaborative international science, research, education and communication focusing on the Arctic and Antarctic regions. For logistical reasons, the IPY covered the 2-year period from March 2007 through March 2009 to allow for a full season of summer scientific activity in both the Arctic

T

and Antarctic. The years 20072008 marked the 50th anniversary of the International Geophysical Year (IGY) and the third IPY. This event was designated the 4th IPY by the National Academy of Science, International Council of Science, the World Meteorological Organization, the Arctic Council and many other international organizations. This period of focused scientific activity


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Alan J. Parkinson

promised to further our understanding of the physical and social process in polar regions, examine their globally connected role in the climate system and establish research infrastructure for the future, and serve to attract and develop a new generation of scientists and engineers with the versatility to tackle complex global issues (www.ipy.org) (1). In contrast to previous polar years, the IPY 20072009 had a much wider scientific scope including for the first time, fields of direct societal importance such as ecosystem and human health, and the development of indigenous societies and economics. The theme for the human dimension was established to ‘‘investigate the cultural, historical, and social processes that shape the sustainability of circumpolar human societies, and to identify their unique contributions to global cultural diversity and citizenship’’ (1).

History of circumpolar health research The scientific program of the IGY 19571958 did not have a human health component; however, it did provide the catalyst for the beginning of the ‘‘Circumpolar Health Movement’’ a collaborative international effort to focus on human health in the Arctic. In 1957, the Nordic Council appointed a committee for Arctic Medical Research that resulted in the publication of the Nordic Council for Arctic Medical Research Report. Also in 1958, the idea for an International Biological Program was conceived, and it was implemented in 1967 as a biological analogue for the IGY, which had served as a successful catalyst for Arctic and Antarctic research in the physical sciences (2). Although human health is new to IPY activities, there is a well-established history of cooperation and collaboration in health research between polar nations. The first exploratory conference on Medicine and Public Health in the Arctic and Antarctic, sponsored by the World Health Organization (WHO), was held in Geneva from 28 August*to September 1962. It concluded that there was a need to stimulate high-latitude research especially on health problems (3). As a result of these combined events, the first international circumpolar health symposium was held in Fairbanks, Alaska, in 1967, and it was agreed to hold similar symposia every 3 years (4). Twenty years later, these meetings resulted in the formation of the International Union for Circumpolar Health (IUCH). The IUCH is a non-governmental organization comprising of an association of 5 circumpolar health organizations: the American Society for Circumpolar Health, the Canadian Society for Circumpolar Health, the Nordic Society for Arctic Medicine, the Siberian Branch of the Russian Academy of Medical Sciences and the Danish Greenlandic Society for Circumpolar Health. The IUCH promotes circumpolar collaboration and cooperation through the activities of its working groups in various fields of health and medicine (www.iuch.net).

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Outreach and communication are provided through the hosting of the triennial International Congress on Circumpolar Health (http://www.icch15.com). The Arctic Council (www.arctic-council.org), established in 1996, is a Ministerial intergovernmental forum promoting cooperation, coordination and interaction between the 8 Arctic States (the US, Canada, Denmark/Greenland, Iceland, Norway, Sweden, Finland and the Russian Federation) including Arctic indigenous populations on common Arctic concerns such as sustainable development and environmental protection in the Arctic. Arctic Indigenous peoples are represented at the Arctic Council by Permanent Participant organizations Arctic Athabaskin Council, Aleut International Association, Gwitch’n Council International, Inuit Circumpolar Council, Russian Arctic Indigenous Peoples of the North and Saami Council. The scientific work of the Arctic Council is carried out in 6 working groups: The Arctic Contaminants Action Program (ACAP), the Arctic Monitoring and Assessment Program (AMAP), Conservation of Arctic Flora and Fauna (CAFF), Protection of the Marine Environment (PAME), Emergency Prevention Preparedness and Response (EPPR) and Sustainable Development Working Group (SDWG). The working groups conduct research and other activities in the areas of monitoring, assessing and preventing pollution in the Arctic; climate change; biodiversity conservation; emergency preparedness and response; sustainable development; and the monitoring and assessment of living conditions of Arctic residents including human health. The human health activities of the Arctic Council primarily reside in the AMAP and SDWG.

IPY and the Arctic human health initiative The Arctic Council recognized that IPY 20072008 represented a unique opportunity to further stimulate cooperation and coordination on Arctic health research and increase the awareness and visibility of Arctic regions. The Arctic Human Health Initiative (AHHI FP # 167) was a US-led Arctic Council IPY coordinating project that aimed to build and expand on existing Arctic Council and IUCH’s human health research activities. The project aimed to link researchers with potential international collaborators and to serve as a focal point for human health research, education, outreach and communication activities during IPY. The overall goals of the AHHI was to increase awareness and visibility of human health concerns of Arctic peoples, foster human health research and promote health strategies that will improve health and well-being of all Arctic residents. Proposed activities to be recognized through the initiative included: (a) Expanding research networks that will enhance surveillance and monitoring of health issues of


Arctic Human Health Initiative

concern to Arctic peoples, and increase collaboration and coordination of human health research; Fostering research that will examine the health impact of anthropogenic pollution, rapid modernization and economic development, climate variability, infectious and chronic diseases, intentional and unintentional injuries; Promoting education, outreach and communication that will focus public and political attention on Arctic health issues, using a variety of publications, printed and electronic reports from scientific conferences, symposia and workshops targeting researchers, students, communities and policy makers; Promoting the translation of research into health policy and community action including implementation of prevention strategies and health promotion; and Promoting synergy and strategic direction of Arctic human health research and health promotion.

Several circumpolar human health monitoring networks already exist and could form the basis for the establishment of a SAON for human health. These currently include the AMAP Human Health Assessment Program, the International Circumpolar Surveillance (ICS) of Infectious Diseases and the Circumpolar Health Observatory (http://circhob.circumpolarhealth.org). Together these networks could provide:

As of 31 March 2009, the official end of the IPY, AHHI represented a total of 38 proposals, including 21 individual Expressions of Intent (EoI), and 9 full proposals (FP), submitted to the IPY Joint Committee for review and approval from lead investigators from the US, Canada, Greenland, Norway Finland, Sweden and the Russian Federation. In addition, there were 10 National Initiatives (NI-projects undertaken during IPY beyond the IPY Joint Committee review process). Individual project details can be viewed at www.arctichealth.org. The AHHI currently monitors the progress of 28 individual active human health projects in the following thematic areas: health network expansion (5 projects), infectious disease research (7 projects); environmental health research (7 projects); behavioral and mental health research (4 projects); and outreach education and communication (5 projects). While some projects have been completed, others will continue well beyond the IPY. The progress of these projects is summarized in this report (Table I).

Existing networks that could provide the basis for such an observing system include:

(b)

(c)

(d)

(e)

Expansion of research networks The establishment of well-coordinated and Sustained Arctic Observing Networks (SAON) was a major objective of the IPY (www.arcticobserving.org). The goal was to develop long-term Arctic-wide observing activities that provide free, open and timely access to high-quality data for both the scientific and societal communities. In 2006, the Arctic Council Ministers requested that the AMAP together with other Arctic Council working groups and external partners create a coordinated Arctic Observing System to monitor Arctic Change. One of the priorities of the SAON process is to identify existing observing networks and opportunities for improving access and data sharing.

(a) An international circumpolar collaborative health information system; (b) Systematic standardized, consistent methods in data collection, analysis and reporting; (c) Ability to monitor trends and patterns in health status, health determinants and health care; (d) Quantitative evidence for planning and evaluation of health programs and services; and (e) A system that is population based and aggregated by administrative regions in all circumpolar countries.

International circumpolar surveillance Established in 1999, the ICS system is an integrated population-based infectious disease surveillance network system, linking hospital and public health laboratories in the Arctic Circumpolar countries (USA/Alaska, Canada, Iceland, Greenland, Norway and Finland) (5,6). Accomplishments during IPY included: an expansion of surveillance to include tuberculosis; an effort to include northern regions of the Russian Federation in this system; and the establishment circumpolar working groups to focus on research aspects of viral hepatitis (EoI # 1109), diseases caused by Helicobacter pylori, and sexually transmitted infections (STIs) (EoI #1150). The purpose of the ICS system for infectious diseases is to establish a surveillance network of hospital and public health laboratories throughout the Arctic (7). The network allows the collection and sharing of uniform laboratory and epidemiologic data between Arctic countries that defines the prevalence of infectious diseases of concern to Arctic residents and assists in the formulation of prevention and control strategies (810). While currently focused on prevention and control of infectious disease, the system could be adapted to monitor other human health issues of concern in Arctic countries and serves as a model for a Sustainable Arctic Observing Network for human health. Arctic Monitoring and Assessment Program: Human Health Assessment Group As part of the IPY a joint Arctic Monitoring and Assessment Program (AMAP) and Northern Contaminants Program (NCP) symposium was held in Iqaluit, Nunavut, Canada, from 1012 June 2009 (FP # 145).


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Table I. Active Arctic Human Health Initiative (AHHI) Proposals as of March 31, 2009 Project Title

Lead Country(s)

EoI/FP#

Expansion of Networks International Circumpolar Surveillance

USA

1150

International Network for Circumpolar Health Researchers http://www.inchr.com/ Arctic Health Research Network http://www.arctichealth.ca/

Canada Canada

516 449

Survey of Living Conditions in the Arctic: Remote Access

Denmark

386

Arctic Community-Based Environmental Monitoring, Observation and Information

USA

922

Canada

253

Stations Phase 1: Bering Sea Sub-network Research The Inuit Diet and Health Study: Inuit Health in Transition Integrated Research on Arctic Marine Fat and Lipids

NI1

Inuit Health Survey: Inuit Health in Transition and Resiliency (http://www.inuithealthsurvey.ca/?navhome) Genetics and Environmental Risk Factors for Complex Diseases: A study of the Saami population

Sweden

Center for Alaska Native Health Research

USA

Does Exposure to Persistent Organic Pollutants (POPs) increase the risk of breast cancer?

Denmark

An Epidemiological Study of the Cumulative Health Effects of POPs and

USA

NI2 1274 NI3 1257 NI4

Mercury in Subsistence Dependent Rural Alaska Natives. The burden of Infectious Diseases in Greenland-means of evaluation and reduction

Denmark

1107

Hepatitis B in aboriginal Populations in the Arctic: Alaska Natives, Canadian Inuit, First Nations Peoples, Greenland Inuit and Russian Native Populations.

USA

1109

Addressing Viral Hepatitis in the Canadian North

Canada

NI5

Sexual Health and Sexually Transmitted Infections in Northern Frontier Populations.

Canada

1147

Engaging Communities in the Monitoring of Zoonoses, Country Food Safety and Wildlife Health

Canada

186

Evaluation of the impact of an immunization program combining pneumococcal conjugated vaccine

Canada

1119

and inactivated influenza vaccine in Nunavik children, Province of Quebec, Canada Prevalence of Human Papillomavirus Infection and Cervical Dysplasia in the North West Territories

Canada

1121

Health and social condition of adoptees in Greenland - a comparative register and population based field study.

Denmark

1201

Healthy Lifestyle Projects

USA

1271

Negotiating Pathways to Adulthood: Social Change and Indigenous Culture in 4 Circumpolar Communities

USA

1266

Mental and Behavioral Health Issues in the U.S. Arctic Outreach, Education, Communication:

USA

NI6

The Circumpolar Health and Wellbeing: Research program for Circumpolar Health and Wellbeing,

Finland

1045

Finland

1046

USA

1223

Telemedicine Cooperation Project

USA

1270

Arctic Monitoring and Assessment Program Human Health Assessment Group Conference.

Canada

145

Climate Change and Impacts on Human Health in the Arctic: An International Workshop on Emerging Threats and Response of Arctic Communities to Climate Change

USA

NI7

Creation of an ‘‘adoptees-database’’

Graduate School of Circumpolar Wellbeing, Health and Adaptation, and International Joint Master’s Program in Circumpolar Health and Wellbeing Scientific and professional supplements on human health in polar regions-the International Journal of Circumpolar Health Development of a Women’s Health and Well-Being Track at the 14th International Congress on Circumpolar Health in Yellowknife, NWT July 2009

Canadian training, communications and outreach projects The Inuit Cohort: A Community of Research Practice Across Canada

NI8

http://www.ciet.org/en/documents/projects_cycles/2007102165919.asp Healthy Foods North NWT http://www.hlthss.gov.nt.ca/sites/healthy_foods_north/default.htm

NI9

Pan-Arctic Interactive Communications Health Project http://www.naho.ca/inuit/wellnessTV/index.php

NII0

# The table lists proposals by lead country submitted to the Joint Committee as Expressions of Interest (EoI), or Full Proposal (FP-in bold). Projects undertaken during IPY beyond the IPY Joint Committee review process are listed as National Initiatives (NI).

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The AMAP has been coordinating circumpolar monitoring and assessment of atmospheric pathways, biota impacts, food chain dynamics and human health issues for environmental contaminants since 1991 (http://www. amap.no/). The contaminants have included persistent organic pollutants (POPs both historic and emerging compounds), metals, and radionuclides of concern in the circumpolar world. The AMAPArctic Human Health Assessment Group (AHHAG) has members in all 8 circumpolar countries and has completed 3 assessments on the human health impacts of arctic environmental contaminants (1113). These assessments include human monitoring data, dietary studies, health effects studies and risk management strategies to mitigate the effects of contaminants. The AHHAG has effectively functioned as an Arctic Observing Network for environmental contaminants in the circumpolar north and could work with the other human health observation networks to give an integrated picture of circumpolar human health.

International Network for Circumpolar Health Research The IPY saw the establishment of the International Network for Circumpolar Research (INCHR) (EoI #516). This is a voluntary network of individual researchers, research trainees, and supporters of research based in academic research centres, Indigenous people’s organizations, regional health authorities, scientific/professional associations and government agencies, who share the goal of improving the health of the residents of the circumpolar regions through international cooperation in scientific research (www.inchr.com). The goals of INCHR are to: (a) Conduct, sponsor and promote research programs and projects investigating the patterns, determinants and impact of health conditions among circumpolar peoples and the strategies for improving their health; (b) Support research training at all levels and increase capacity for circumpolar health research in communities, service delivery agencies and higher educational institutions; (c) Facilitate exchange, communication and dissemination of research data; and (d) Strengthen the health information system in the circumpolar region. In 2012, INCHR was merged with the International Association of Circumpolar Health Publishers to form the Circumpolar Health Research Network or CircHNet (http://circhnet.org) and became the publisher of the International Journal of Circumpolar Health (www. circumpolarhealthjournal.net). CircHNet will continue the work of INCHR in organizing annual scientific conferences, summer schools in health research and

support for international exchanges of scientists and trainees.

Arctic Health Research Network The Arctic Health Research Network (AHRN) was launched as a Canadian contribution to IPY 20072008 (EoI # 449; http://www.arctichealth.ca/aboutahrn.html) and was supported by a tri-territorial health fund. The Arctic Health Research Network is a health research network based in the 3 northern territories and a provincial region of Canada. The network aimed to build capacity for northern based health and wellness research though the development of 4 sites in Yukon, Northwest Territories, Nunavut and Labrador. Each was developed under independent boards and is registered under the territorial societies Acts. The initiative supported the development of 3 institutes based in the 3 northern territories and a provincial region of Canada and has 4 sites in Yukon, Northwest Territories, Nunavut and Labrador. The institutes developed included the Institute for Circumpolar Health Research (www.ichr.ca), the Arctic Institute of Community-Based Research (AICBR) (www.aicbr.ca) and the Qaujigiartiit Health Research Centre (AHRN-NU) (http://www.qhrc. ca). Each organization aims to respond to, and provide leadership for, northern regional health and wellness research needs. Survey of Living Conditions in the Arctic-Remote Access The Survey of Living Conditions in the Arctic (SLiCA, FP # 386) is an interdisciplinary and international research project, which was founded in 1998 (14,15). The project is developed in partnership with the local indigenous peoples organizations. SLiCA has accomplished data collection in Canada, Alaska, Chukotka (Russia), Greenland and Sweden (16), and by the end of 2008, interviews among the Sa´mi in Norway and the Kola Peninsula were concluded. The data material consists of approximately 8,000 personal interviews. During IPY, SLiCA intended to expand the understanding of Arctic change by extending the concepts of remote access analysis to the SLiCA international database (17), allowing other researchers to remotely conduct analysis without access to raw data. All interview data (except the Canadian SLiCA data) have been included in an SPSS database and almost 600 tables including survey results based on the interviewing among the Inuit (www. arcticlivingconditions.org). The first phase of this project developed a standardized research design for the measurement of living conditions and well-being among the Inuit, Saami and indigenous peoples of Chukotka (18). The survey was completed in 2006.


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The Bering Sea Sub Network: International Community-Based Environmental Observation Alliance for the Arctic Observing Network Survey of Living Conditions in the Arctic-Remote Access The Bering Sea Sub Network: International CommunityBased Environmental Observation Alliance for the Arctic Observing Network, known as BSSN (FP #922), was a 200809 IPY project implemented by the Aleut International Association in collaboration with the University of Alaska, United Nations Environment Programme Global Resource Databank Arendal and the Alaska Native Science Commission under the auspices of the CAFF working group of the Arctic Council. BSSN is funded by the United States National Science Foundation. The project began as a pilot in 2007 and received an award for a 5-year continuation for Phase II in 2009. BSSN is a network of coastal communities. It began from 6 villages representing 6 indigenous cultures: 3 in the Russian Federation (KanchalanChukchi population; TymlatKoryak population and NikolskoyeWestern Aleut/Unangas population) and 3 in the United Stated (GambellSt Lawrence Island Yupik; TogiakCentral Yu’pik; and Sand PointEastern Aleut/Unangan). During Phase II Savoonga (St Lawrence Island Yupik) and Saint George (Eastern Aleut/Unangan) were added to the network. This project creates a structured framework that provides the means for the systematic collection of information about the environment and lays a foundation for future community-based research. The network also provides for the efficient management of data gathered from community-based environmental observations. The overall goal of the BSSN is to improve knowledge of the environmental changes that are of significance to understanding pan-arctic processes, and to enable scientists, arctic communities, and governments to predict, plan, and respond to these changes. BSSN’s objective was to develop a framework to enable residents in remote Arctic communities to systematically document physical and social changes occurring in their region. This may enhance community resilience under conditions of rapid environmental and social change. BSSN has emerged as an observing network that connects people bound by a common geographic area who share similar traditions, values and ideals (1921).

Research IPY human health research focused on some of the issues of most concern to Arctic residents. These include: the health impacts of environmental contaminants, climate change, rapidly changing social and economic parameters within communities, the changing patterns of infectious and chronic diseases, and the continuing health disparities that exist between indigenous and non-indigenous

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segments of the Arctic populations. While other issues of importance such as injuries and maternal child health were not directly addressed by specific proposals during the IPY and are thus not covered in this report, they do appear as research outputs in broader spectrum outreach, education and communication activities (22). The intensity of research activities and networks during IPY has served as a catalyst to integrate programs, and to promote the concept of communities and researchers working collaboratively. It was hoped research informed by community perspectives would enhance the eventual translation of research into policies and programs that will improve circumpolar health.

Environmental contaminants While socio-economic conditions and lifestyle choices are major determinants of health, contaminants may also have a contributing effect. Toxicological studies show that contaminant levels found in some parts of the Arctic have the potential for adverse health effects in people who rely on a traditional diet for their subsistence. These include the indigenous peoples of the Arctic. Epidemiological studies looking at Arctic residents directly provide evidence for subtle immunological cardiovascular and reproductive effects due to contaminants in some Arctic Indigenous populations (13). If climate change is associated with rising salmon and human levels of POPs and mercury the study would provide data to further support reduction of POPs and mercury production and release, and efforts to reduce global warming. A US-led study, initiated by investigators at the Alaska Native Tribal Health Consortium, examined the cumulative health effects of POPs and Hg in subsistence dependent rural Alaska Natives (NI4). The objectives of the study are to determine time trends in tissues levels of POPs, mercury and omega 3 fatty acids in salmon in the Yukon and Kuskokwim rivers and in a cohort of 200 pregnant Alaska Native Yupik women and their infants. Prior work by this group started in 1998 and contributed data to the AMAP Human Health Assessments in 2002 and 2009 (12,13). This early study in a cohort of 354 Alaska Native Yupik women showed that in general, legacy organic pollutants and mercury levels in these women are quite similar to maternal blood levels from Scandinavian, Icelandic and Inuit women from the western Canadian Arctic. Levels are generally lower than Inuit women from the eastern Canadian Arctic, Greenland, and the Russian Far East. The exceptions are levels of brominated flame retardants (BFRs) and levels of polyfluorinated compounds (PFCs) which are much higher in Alaska Native Yupik women than any other Arctic maternal AMAP populations. Preliminary conclusions thus far show that in this population, the close association of mercury, omega-3 fatty acids, organochlorines and PFCs suggest that the northern marine



subsistence diet is the source of these contaminants and micronutrients. Analysis of health outcomes of mothers and infants, along with possible associations with analytes have yet to be carried out. Another study led by researchers at the Center for Arctic Environmental Medicine, School of Public Health, University of Aarhus, Denmark, examined the risk of the development of breast cancer in Greenlandic Inuit women following exposure to POPs (EoI #1257). Blood levels of POPs in women with breast cancer were compared to controls with respect to age and lifestyle. The bio-effects of POP levels on hormone receptor function were examined (23). The incidence of breast cancer has been traditionally low among the Inuit, but a considerable increase has been observed since the 1970s with rates now approaching respective national populations (22). Previous data in Greenlandic Inuit women suggest that exposure to POPs might contribute to the risk of breast cancer. Rat studies showed that PFCs cause significantly increase in mammary fibroadenomas. This study aimed at evaluating the association between serum levels of POPs/PFCs in Greenlandic Inuit breast cancer cases and their controls, and whether the combined POP related effect on nuclear hormone receptors affect breast cancer risk. Results showed for the first time a significant association between serum PFC levels and the risk of breast cancer (2426). Further investigations are needed to document the study conclusions.

Infectious diseases A continuing major health disparity is the increased morbidity and mortality due to infectious diseases seen among indigenous populations when compared to the non-indigenous populations of the Arctic. These disparities can be resolved with greater understanding of their causes through research and focused efforts at treatment and prevention. Hepatitis B infection occurs at high and endemic rates in Arctic populations. For example, in the past, research had shown that 35% of individuals residing in the Canadian North, 514% of Inuit in Greenland and 310% of Alaska Native people in Western Alaska were infected with hepatitis B virus (HBV) and likely that, if left untreated, 1025% could develop liver cancer or die of cirrhosis. Researchers from the US, Canada, Greenland, Denmark and the Russian Federation have formed a Circumpolar Viral Hepatitis Working Group and are conducting studies to determine the epidemiology of chronic HBV in indigenous populations (EoI #1109). The study monitors patients to determine disease progression; demographic characteristics associated with disease outcome; environmental factors associated with disease outcome including contaminants in the environment and subsistence foods; cofactors such as alcohol intake, obesity and metabolic syndrome; viral character-

istics such as genotype, viral load and mutations that could affect disease outcome. This study allows the identification of barriers to vaccination, the development of registries for research and clinical management and the development of criteria to identify potential treatment candidates, monitoring of treatment outcome and the examination of the role of factors such as demographics, viral genotype and environmental factors in treatment outcome. Already this research group has identified a new HBV sub-genotype (B6), which is only found in indigenous populations of Alaska, Canada and Greenland (27). The group also assisted Greenland in the investigation of an outbreak of hepatitis D super infection in adolescents with chronic HBV in a community in Greenland (28). In addition, this working group has been instrumental in encouraging the Greenland government to adopt universal childhood hepatitis B vaccination in Greenland (29). A Canadian-led IPY study (NI5) examined the genetic diversity of HBV genotypes B6, D and F among circumpolar indigenous individuals and found mutation rates significantly higher in the form of (B6) present in the Canadian Inuit (30). The Canadian study also examined the prevalence and long term out-come of occult hepatitis B (where only viral DNA and no serological markers of infection are detectable in blood). They studied 3 northern Canadian populations and found that occult hepatitis B is less common than hepatitis B and was not associated with any long term adverse clinical outcome (31). Similarly reported rates of STIs are disparately high among indigenous populations of the Arctic (32). Research in Canada, the US, and Greenland (EoI #1147) aimed at building capacity to examine individual, social and environmental factors that influence perceptions of sexual health and STIs is being conducted by researchers and communities using participatory methods (33,34). The aims include a description of the basic epidemiology of sexual health and STIs and to identify communities at risk and targets for capacity building and interventions. Preliminary results indicate that Mycoplasma genitalium is as prevalent as Chlamydia trachomatis in Greenland and that social and cultural norm around sexual health communication, trust, drinking and sex appear to influence individual sexual behaviors and risk for STIs (35). Based on this research, the National Science Foundation has granted US, Canadian, Greenlandic and Danish researchers new funds to explore community based participatory methods in Greenland and develop a social intervention focusing on sexual health communication with families and relationships. Canadian researchers are examining the potential for incorporating Human Papillomavirus (HPV) DNA testing into the present screening program (EoI #1121). This project examined HPV infection and cervical dysplasia (precancerous cells) in women of the Northwest


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Territories, Yukon, Nunavut and Labrador to determine general prevalence rates, types of HPV and risks associated with the development of HPV. The aim is to provide scientific evidence for policymakers and local public health workers to assist in the planning and implementation of cancer control programs. Results from 14,598 bio-samples showed an overall HPV prevalence 25.2%, of which 78.6% with high risk types and 32.5% with multitypes infection. The HPV prevalence was approximately 40% higher among the aboriginal than the non-aboriginal population, overall and in most of the age-groups. The prevalence of HPV infection was elevated in the young aboriginal population in the NWT (3638). HPV infection attributes to more than 80% of abnormal cervical cytology cases. An effective vaccine program may reduce the cervical abnormality to lower than half of its current level. With their strong hunting traditions and subsistence based on wild game, Arctic indigenous peoples are at increased risk for zoonoses and parasitic infections acquired from infected meat. Zoonoses refer to a group of diseases caused by organisms that are usually present in animals but are transmitted to and cause disease in humans. As temperatures warm and habitats change, some parasites could move northward with the migration of their wildlife hosts, and others will increase their density due to optimal temperatures for replication. These factors, together with other environmental changes (water availability, ice and snow cover, ocean currents, extreme weather events, forest fires), will favour a shift in the distribution of hosts and zoonotic diseases threats to the safety of traditional subsistence foods (39,40). Foodborne parasites such as Trichinella sp. and Toxoplasma gondii are significant Arctic zoonoses endemic in some regions and are directly related to consumption of country food (41,42). Others such as Anisakidae nematodes and the bacteria Salmonella sp. and Escherichia coli 0157:H7 can become a zoonotic issue with warmer weather. A study in Canada has resulted in the development of simplified pre-screening diagnostic tests for Salmonella sp. and Escherichia coli 0157:H7 (43) and into the development of qPCR techniques and multispecies ELISA for Toxoplasma gondii detection (EoI# 186). The study provided equipment and training for northerners to collect samples and the evaluation of some of these tests in 3 northern communities. Results show that Trichinella infection is present in northern carnivore mammals, except for seals and beluga. The 2 species present, Trichinella nativa and T6, are freeze-resistant. Collection and storage of blood using a filter paper technique is useful for Toxoplasma detection but needs to be validated with other diseases (44). Anisakidae nematodes are present in marine fish and mammals traditionally eaten by eastern Canadian Inuit. Data of each disease studied in Canadian wildlife will be included

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into the Canadian Cooperative Wildlife Health Centre database linked to the IPY database centre. The ICS project has shown that Streptococcus pneumoniae is one of the leading causes of pneumonia, meningitis, bacteremia, septic shock and otitis media in Arctic indigenous populations, particularly among children and the elderly (8). For example, the incidence rates of invasive pneumococcal disease in Inuit are approximately 4 times that of non-Inuit. A Canadian study is retrospectively analyzing immunization and laboratory records of persons living in Nunavik to describe the epidemiology of invasive pneumococcal disease in relation to vaccine use during the period 19972010 (EoI # 1119). The implementation of vaccine programs in this region in 2002 controlled an outbreak of invasive pneumococcal disease in young adults caused by pneumococcal serotype 1. Use of the 7-valent conjugate vaccine in children markedly reduced the rate of disease caused by these 7 most common serotypes in children, but did not prevent disease caused by non-vaccine types (45). The impact of a 13-valent vaccine is being evaluated in Nunavik. An evaluation of the impact of the 7-valent vaccine on hearing loss in children showed that the vaccine had no significant impact on reducing major audiology disorders (46). The IPY provided the opportunity to strengthen surveillance and research on infectious diseases in Greenland (EoI #1107). This project, a cooperation between Greenland and Denmark, addressed the burden of infectious diseases in Greenland by establishing research programs to evaluate long-term consequences of certain infectious diseases, to evaluate the use of routine surveillance data, to initiate intervention trials in order to prevent infectious diseases, to seek implementation of results in the Greenland health system and to establish cooperation with public health and research organizations in other countries. Specific studies under this project included a validation of the Greenlandic inpatient register, the initiation of tuberculosis studies (4752), an evaluation of the distribution of bacterial pathogens causing invasive disease (8,53,54), a study of the long-term consequences of hepatitis B (27 30,55), a study of the association between Epstein Barr virus and various cancers (56,57), a study of HIV drug resistance (58,59), a study of HIV and living conditions (60), a study on gene mutations and hearing (61), longitudinal studies on chronic otitis media (62,63), a study of the first case of Q fever endocarditis in Arctic Areas (64) and a study of the aetiology of viral respiratory pathogens among Greenlandic children. In collaboration with Canadian researchers, a nationwide study of viral pathogens in children hospitalized with lower respiratory tract infections in Greenland is ongoing. With researchers in Canada and the USA, the network organization is involved in studies of



epidemiological, microbiological and social aspects of STIs (EoI # 1109) (3335). These activities have resulted in the creation in 2012 of a network of circumpolar infectious disease researchers by the Greenlandic, Danish and US governments as part of a capacity building bilateral project to promote continued collaboration, sharing of results and best practices to investigate impact of climate change on infectious diseases, and builds on existing infectious disease collaborations. A purpose is to encourage early career researchers and indigenous peoples to participate in an international network of researchers.

Life-style, diet and nutrition Considerable life-style changes have occurred over the past decades among the indigenous peoples in the circumpolar region. Parallel to this has been a change in disease patterns, with an increase, for example, in cardiovascular diseases, obesity and diabetes. Among the main causes are alterations to the diet and decreased levels of physical activity as the population changes from their traditional hunting and fishing economy to more Westernized living conditions. Several large IPY activities were initiated to address some of these issues. A large international study entitled ‘‘The Inuit Health in Transition (EoI #760; NI1, NI2) and Inuit Diet and Health Study (FP #253)’’ was proposed to cover a cohort of over 7,000 Inuit adults in Alaska, Canada, and Greenland during IPY. The Government of Canada Federal Program for IPY funded a major component of this international study during 200708 in the Inuvialuit Settlement Region (ISR) of the Northwest Territories, Nunavut and the Nunatsiavut region of Labrador. Known as the IPY-Inuit Health Survey, and utilizing the Canadian coast guard ship Amundsen, which was equipped with research and laboratory facilities, 33 coastal communities were visited and 3 inland communities were visited by separate survey teams (65). A total of 1,901 households participated (68%), with a total of 2,595 participants aged 18 years or older. The cross-sectional adult survey provides baseline data concerning the risk factors for cardiovascular disease and type 2 diabetes mellitus in the Inuit undergoing acculturation as well as evaluates social support and other determinants of resiliency and self-reported health. Matching funding from the Northern Contaminant Program in Canada also supported the research on dietary contaminants exposure associated with country food consumption. The most pressing health concerns for Inuit adults were food insecurity (66,67), overweight and obesity and the emergence of obesity-related chronic diseases (68), iron deficiency in women of reproductive age (69,70), vitamin D deficiency (71) and the high obesogenic potential of high sugar-drink consumption (72,73). These

health priorities are interlinked in the context of economic disadvantages and high market food costs in the Arctic. Most Inuit Health Survey participants had blood contaminant concentrations below guidelines set by Health Canada even though metal and POPs body burdens commonly exceed exposures observed in the general population of Canada (74). Results on contaminant nutrient interactions showed a strong correlation between mercury (Hg) and nutrients (selenium and n-3 fatty acids), suggesting that efforts to decrease Hg exposure must emphasize the overall healthfulness of traditional foods and be designed to prevent concomitant harm to the nutrient intakes of Inuit (75,76). In addition, 388 children aged 35 years from 16 Nunavut communities took part in the Nunavut Inuit child health survey. The goal of the child health survey was to evaluate nutritional status, breastfeeding and complementary feeding practices, food security, access to country food, respiratory tract and ear infections, and diet quality. Results from the child survey indicated that nearly 70% of Inuit preschoolers resided in households rated as food insecure [69.6%; 95% confidence interval (CI) 64.774.6%]. Overall, 31.0% of children were moderately food insecure, and 25.1% were severely food insecure, with a weighted prevalence of child food insecurity of 56.1% (95% CI 51.061.3%) (77). Furthermore the overall prevalence of overweight was 50.8% (78) and vitamin D deficiency and insufficiency were highly prevalent among Inuit preschoolers living in Nunavut (79). Nearly 25% of children had hair Hg concentrations equal to or higher than 2 mg/g (WHO reference level). There was a significant correlation between mercury levels in children’s hair and that of the adults in the same household. For children, beluga muktuk, narwhal muktuk, ringed seal liver, fish, caribou meat and ringed seal meat were the major dietary sources of mercury. Both local and international policies are needed to lower the intake of dietary Hg exposure among Inuit children in the circumpolar north. A Swedish IPY project evaluates a northern Swedish population with known demographic and environmental exposures to identify genetic and environmental factors that contribute to health status (EoI #1274). In this study, cross-population comparisons are used to study genetic and environmental risk factors among populations with widely differing origins and environments. The study measures a broad spectrum of environmental (e.g. diet, physical activity and daylight exposure) and genetic (e.g. single-nucleotide polymorphisms) factors with potential relevance for health risk. A comprehensive set of health indicators and diagnoses of cardiovascular, orthopaedic and metabolic diseases has been collected. The laboratory analysis of blood lipids comprising several hundreds of lipid species will give unique insights into the human metabolism under extreme living


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conditions. Studies of rural populations can make substantial contributions to basic research to understand environmental and genetic determinants of disease. The European Special Population Network (EUROSPAN) provides a platform combining studies of rural populations from different parts of Europe to leverage these for collaboration with large international consortia (8082). In the US the Center for Alaska Native Health Research (CANHR) at the University of Alaska Fairbanks used the IPY momentum to build a collaborative research presence in Alaska Native communities (NI4). Research focused on prevention and reduction of health disparities by seeking new knowledge through basic and applied research that can ultimately be applied to understand, prevent and reduce health disparities in indigenous communities (http://canhr.uaf.edu/) (83). The centre studies behavioral, dietary and genetic factors related to obesity diabetes and cardiovascular disease risk in Alaska Natives of south-western Alaska. CANHR includes studies related to substance abuse and suicide prevention, the development of novel dietary biomarkers, contaminants and the safety of subsistence foods, stress, gene by environment interactions and nutrition research. All CANHR studies employ community based participatory research approaches.

Behavioral and mental health Behavioral and mental health disorders are common worldwide and circumpolar regions are not exempt from this burden. Contemporary dynamics of rapid social change have dramatically affected the political, cultural and economic systems of circumpolar indigenous people. Alcohol abuse and suicide have been highlighted as significant issues in northern regions (84,85). During IPY, there were a number of research projects which explored behavioral and mental health disorders and the relationships between outcomes and environmental factors, including social determinants. The Inuit Health Survey collected information on mental and community wellness. Findings will provide information on the burden of mental illness, and also evaluated social support and other determinants of resiliency and self-reported health (86). In Nunavik, a cohort study was carried out which focused on exposure to environmental contaminants and child behavior. The study also explored the impact of lifestyle factors, such as smoking, alcohol and drug abuse during pregnancy, on multiple domains of child development and behavior (87). Two CANHR-affiliated studies focus on behavioral health research. This US-led study examined social change and indigenous culture in 5 circumpolar communities by exploring responses to rapid social transition through the life experiences of circumpolar youth in order to identify resilience processes that might guide

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prevention, treatment and policy (EoI # 1266). This study completed over 100 youth life history interviews from Alaska Inupiat, Alaska Yup’ik, Canadian Inuit, Norwegian Saami and Siberian Eveny communities. The project team identified shared and stressors and patterns of resilience in the transition to adulthood across these different circumpolar settings along with innovative approaches in youth-driven participatory research (88,89). Elluam Tungiinun ‘‘Toward wellness’’ is a culturally based preventive intervention to reduce suicide risk and co-morbid underage drinking among Alaska Native Yup’ik Eskimo youth. This study represents the next stage in a 15-year community-based participatory research process with Alaska Native people (9092). The goal is to identify protective factors from alcohol abuse and suicide (9295), and to use this knowledge base to mount a 5-year community based participatory research prevention trial. The trial will enrol 239 youths, ages 1218, in 5 rural remote Yup’ik communities in order to test effectiveness post intervention using a randomized dynamic wait list control design and to understand outcomes among subgroups (96). A Danish study examined the health and social condition of adoptees in Greenland, where there are a large number of adoptees and children institutionalized (EoI # 1201). The study explored how adoption and collective care have an impact on well-being, family health and social conditions. Adoption is closely linked to social organization, identity, cultural openness and collective consciousness; this study identified settings in which adoption was linked to child neglect and lack of care. The study also examined parents’ and care givers’ control and coping strategies. The study concluded that contrary to findings related to adoptees in Western societies, being an adoptee in Greenland does not increase the risk for psychiatric admission (97).

Health services delivery The circumpolar regions experience unique challenges in the delivery of health services because of widely dispersed populations and geographic obstacles to service delivery. During IPY 20072008, opportunities were created for cross-border partnerships to explore needs related to service delivery. The Northern Forum, a forum of northern regional governments (www.northernforum. org), cooperated with the Alaska Federal Health Care Access Network (AFHCAN) to implement a strategic and innovative solution to address health care needs of 2 regions in the Arctic. Together the Northern Forum and AFHCAN facilitated cooperation in telemedicine technology expertise between Alaska, the Republic of Sakha and Khanty-Mansyisk region in Russia (EoI # 1270). The goal of the project was to promote the establishment of a mutually beneficial collaboration in telemedicine,



telehealth, mobile medicine and distance learning in remote areas of the Russian north. This project is an important first step in both improving technologies to enhance access to care and utilize existing forums to promote cross border partnerships and activities. Mental health services are also of importance in the north and efforts are required to enhance service delivery. The Northern Forum developed and promoted The Healthy Lifestyle Projects (EoI # 1271), which provided information exchange and training opportunities to advance care and treatment of Arctic residents with mental health issues. While the health service delivery research field is underdeveloped in the north, these projects identify key area of importance and play an important role as we begin to understand and develop best practices to improve services and programs in northern regions.

Outreach education and communication An important aspect of IPY was, and will continue to be, the promotion of education, outreach and communication, which will focus public and political attention on Arctic health issues; increase dialogue between researchers, policymakers and communities; increase distribution of scientific information to scientists and the public through conferences, symposia, workshops and a variety of electronic and printed media; and increase community involvement in research activities and foster a ‘‘new’’ generation of Arctic health scientists.

Symposia and workshops The IPY was highlighted by the occurrence of the 13th International Congress on Circumpolar Health held in Novosibirsk, Russian Federation, from 1216 June 2006, the ‘‘Gateway to the IPY’’ for the circumpolar health community. This congress was put on by the International Union of Circumpolar Health (IUCH) and brought together 200 circumpolar health care professionals, workers, researchers, policymakers and indigenous community members. The meeting presented a forum for discussion on their respective visions and priorities for human health activities for the IPY and beyond. These discussions resulted in recommendations that emphasized the role of communities in research planning, research activities and the translation of research findings into actions that would benefit the health and well-being of Arctic communities (98). The Women’s Health Working Group of the IUCH was reactivated at that congress in June 2006 (EoI #1223). Participants identified at least 4 areas of mutual interest, including but not limited to (a) perinatal health systems and challenges (99,100); (b) infectious disease, particularly HPV and the new vaccine (35,36,101); (c) interpersonal violence prevention; and (d) health communication and health literacy (102). The Women’s

Health Working group maintains an active list of 60 members to share resources and opportunities and sponsored a pre-congress seminar on Health Literacy and Northern Women’s Health in Fairbanks in August 2012 that attracted 50 participants. There have been several collaborative projects that have come out of this network, including a Pan-Arctic Inuit Wellness TV Series and an April 2012 special issue of the IJCH focused on Participatory Research and Ethics (103,104). At the end of IPY, the 14th International Congress on Circumpolar Health was held in Yellowknife, Northwest Territories, Canada, from 1216 July 2009. The Congress recognized the end of the Polar Year through its theme, ‘‘Securing the IPY legacy: from research to action’’. While results from much of the research conducted over the IPY were still pending, the congress program contained a broad cross section of presenters, sessions and preliminary results from the IPY. The sessions allowed for complimentary perspectives of researchers, clinicians, community representatives and governments on numerous topics which impact public health, health services delivery, the research process and Indigenous wellness in our circumpolar regions. Presentations demonstrated instances where research findings are applied in numerous settings, with uptake by clinicians, community organizations and governments. Presentations also recognized the contributions of numerous stakeholders through the research process with a particular focus on community engagement and participatory methods (105). The IPY Oslo Science conference (812 June 2010) was also a major venue for presenting all science conducted during the IPY 20078 (www.ipy-osc.no). Because this was the first time human health was a thematic area of research during an IPY, the meeting presented the opportunity to highlight human health activities conducted in both the Arctic and Antarctic during the IPY (www.ipy-osc.no/session/t4-1). At this conference, there were 6 human health sessions in all with a total of 27 presentations, including 31 poster presentations. A follow-up IPY 2012 ‘‘From Knowledge to Action’’ Conference (2227 April 2012) held in Montreal, Canada (www.ipy2012montreal.ca) and brought together over 2,000 Arctic and Antarctic researchers, policy- and decision-makers, and a broad range of other interested parties from academia, industry, non-government, education and circumpolar communities including indigenous peoples. The conference focused on the translation of IPY research findings to the development of an agenda for action for the future. The conference featured 6 human health and well-being sessions, a plenary panel on Communities and Health, and an action forum on Improving Access to Quality and Sustainable Health Care in Arctic Communities. Issues surrounding human health and well-being, food security, mitigation and


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adaptation will increasingly be the focus for science and public health work in the coming decades. The Arctic like most other parts of the world has warmed substantially over the last few decades. The impacts of climate change on the health of Arctic residents will vary depending on such factors as age, socio-economic status, lifestyle, culture, location and capacity of the local health care infrastructures to adapt. It is likely that the most vulnerable will be those living close to the land in remote communities and those already facing health related challenges (106). Climate change and health workshops (NI7) were convened in Anchorage, Alaska, as part of the 2008 Alaska Forum on the Environment (www.akforum.com) (107); a meeting in Moscow May 2008 organized by UNDP, WHP and UNEP resulted in report by the United Nations in the Russian Federation ‘‘Climate Change Impact on Public Health in the Russian Arctic’’ (www.unrussia.ru/en/documents) (108,109). A meeting coordinated by UNESCO and hosted by the Principality of Monaco in Monte Carlo, 36 March 2009, explored aspects of sustainable development in the Arctic in the face of climate change and called on the Arctic Council and the WHO to take action on human health recommendations identified by chapter 15 of the ACIA (106,110). A joint AMAP and NCP symposium was held in Iqaluit, Nunavut, Canada, 1012 June 2009 (FP # 145). At this meeting, the third NCP and AMAP Human Health Assessments reports on environmental contaminants were released, and the results were discussed (13,111,112). The symposium demonstrated that the overall management of contaminants issue in the Arctic globally through implementation of the Stockholm Convention and the United Nations Economic Commission for Europe Convention on Long-Range Transboundary Air Pollution Protocols has been effective in reducing the health risks to northern populations from environmental contaminants. While the results indicate that there are declines in many contaminants in several Arctic Regions, there are still indications that there may be subtle health effects (cardiovascular, immunological and behavioral) due to contaminants in some Arctic Indigenous populations. The symposium reemphasized the importance of biomonitoring of POPs and metals to track the efficiency of international treaties, biomonitoring of emerging contaminants, quality control of laboratory methods, health effects research, dietary choice, and risk perception and risk communication (113). The Fogarty International Center at the National Institutes of Health (NIH) together with the US Arctic Research Commission (USARC) and other NIH institutes and CDC, organized a strategy setting conference on the ‘‘Behavioral and Mental Health Research in the Arctic’’ in Anchorage, AK, on 23 June 2009 (NI6).

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The purpose of this meeting was to develop a US Arctic Human Health Research Strategy that will advise the Interagency Arctic Research Policy Committee (IARPC) on the development of an Arctic Human Health Research Plan. This meeting engaged Arctic health stakeholders including US government, scientific and tribal community leaders and international scientists in behavioral and mental health with discussions of current knowledge and gaps in research, with a particular focus on improving our understanding of the risk factors for and barriers to reduce suicide and other behavioral and mental health ailments among Arctic populations. The conference outcome will be a strategy plan that will include specific goals and methods, as well as discussion of potential future research and research training activities on behavioral and mental health in the Arctic (84,85).

Electronic and print media Dissemination in scientific community While the activities of the polar years focused on study implementation and data collection, analysis and dissemination of findings will be ongoing for years to come. During the IPY a number of summary and synthesis documents were created. The International Journal of Circumpolar Health (www.circumpolarhealthjournal.net) produced a series of Circumpolar Health Supplements on topics of general interest and related to the IPY themes (EoI # 1046). To date, 7 supplements have been published as contributions to the IPY: (a) Anthropology and Health of Indigenous Peoples of Northern Russia (114); (b) Diet and Contaminants in Greenland (115); (c) Circumpolar Health Indicators (116); (d) International Circumpolar Surveillance: Prevention and Control of Infectious Diseases (7); (e) Behavioral and Mental Health Research in the Arctic: Strategy Setting Meeting (84); (f) The Arctic Human Health Initiative (117), and (g) the Proceedings of the 14th International Congress on Circumpolar Health (105). The IPY activities related to human health primarily focused on Arctic regions with permanent human inhabitants. However, some health research is conducted in Antarctic regions using transient populations largely comprising of scientists, explorers and occupational workers. The human health needs in these populations tend to focus on emergency medicine, telehealth, rescue and expedition medicine and human response to isolation, cold and remote environments. Populations are small, so studies tend to be descriptive or qualitative. Despite the high level of scientific activity in these regions, scientific programs that explore the human health of these populations were underdeveloped during the IPY. In an attempt to capture health research conducted at both Poles, a Special IPY issue of Rural



and Remote Health (www.rrh.org.au) Human Health at the Ends of the Earth was published in 2010 (118). The International Network for Circumpolar Health Research produced a book Health Transitions in Arctic Populations (22) with contributions from 23 scientists and health care practitioners from all the Arctic countries. It synthesized existing knowledge on the health status of all the circumpolar regions and populations, with specific focus on the indigenous Sa´mi, Dene and Inuit people, their determinants, and strategies for improving their health. In 2011, the IPY Joint Committee published a summary volume on the context, motivations, innovations, planning, implementation and outcomes of all activities conducted during the IPY 20072009. An estimated 50,000 researchers, local observers, educator’s students and support personnel from more than 60 nations were involved in the 228 IPY projects and related national initiatives. Human Health activities are summarized in Chapter 2.11 (119), and are updated in this report.

Multimedia and knowledge sharing The AHHI facilitated the development of the Arctic Health website www.arctichealth.org as a central source for information on diverse aspects of the Arctic environment and the health of northern peoples. The site gives access to health information from hundreds of local, state, national and international agencies, as well as from professional societies and universities. In addition, the Arctic Health Publications Database (currently more than 96,000 records) provides access to Arctic-specific articles, out of print publications and information from special collections held in the Alaska Medical Library. During IPY, a concept for a circumpolar health portal, was developed (www.circumpolarhealth.org). This project is exploring the feasibility of a coordinated venue to capture and promote the activities of circumpolar health organizations and initiatives. The website also incorporates Facebook and Twitter and has dedicated channels for You Tube, podcasts and Flickr. These mechanisms allow for storage and access of photos, audio files and video. These tools are especially valuable to share information and outputs related to youth driven and participatory research projects. In addition to web-based media, radio and TV still play an important role in the sharing of information with circumpolar residents (NI10). A series of 3 live TV call-in shows on Inuit wellness was developed under the umbrella of the Pan-Arctic Interactive Communications Health Project. TV programs were produced and focused on the current health issues of importance to Inuit, including (a) Inuit men’s health and wellness; (b) Inuit maternal care; and (c) Inuit youth and coping. Each show was moderated and featured panel discussions about programs and research with community representatives

and physicians, video vignettes and interactions with the studio audience and participants by Skype, phone and e-mail. The television broadcasts reached a wide audience by airing on networks in Canada and Alaska. This project was an innovative, multidimensional, collaborative health communication project that raised both interest and awareness about complex health conditions in the North and stimulated community dialogue and potential for both local and regional collaborative action. Ongoing evidence-based resources for health education and community action developed through this program were assembled and archived in digital format (www. naho.ca/inuit/e/TVseries) to increase accessibility for otherwise isolated individuals and remote communities.

Education and training initiatives Education and training in the discipline of circumpolar health is as varied and broad as the number of topics related to human health which are explored in circumpolar regions. Thus, education and training activities through the polar years have tended to be cross-cutting and integrated in research programs. Activities have included the support of graduate students and training of community partners. Many health research initiatives now employ community based participatory methods in which training in research methods, data collection and dissemination practices are integral components of the methodology. Examples of community participation have been demonstrated in programs such as the Inuit Health Survey (NI2), Healthy Foods North project (NI9) and the Inuit Cohort (NI8), an education initiative to promote graduate education for Inuit. All these initiatives are important as research methods are improved to incorporate academic and community perspectives. The evaluation of the Pan-Arctic Inuit Wellness TV Series project provides specific lessons to build a strong foundation for a community-professional-academic partnership (120). In addition, the Centre for Arctic Medicine, Thule Institute, University of Oulu, Finland (http://arctichealth. oulu.fi), has a research and education program dedicated to circumpolar health and well-being, the main focus of the research projects are environmental health, marginalization and mental health (EoI# 1045). It is delivered in close collaboration with the University of the Arctic (www.uarctic.org). The program offers both PhD and Master’s programs in the field of health and well-being in the circumpolar regions. The International Master’s program started in 2008 with 14 students and the third set of 15 students starts on September. Three graduated students continue their studies as PhD students. Other partners of the Master’s program that provided courses towards the degree program include the Center for Health Education (Nuuk, Greenland), Lulea˚ University of Technology (Lulea˚, Sweden), Northern Medical State University (Arkhangeslsk, Russia),


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NARFU (Arkhangelsk, Russia), University of Lapland (Rovaniemi, Finland), and University of Manitoba (Winnipeg, Canada), as well as the Cross Border University of Barents area. The University of the Arctic’s international PhD program ‘‘Arctic Health and Wellbeing’’ started in 2012. The main work for course development continues through 2013 and institutional accreditations will be sought, while in 2014 the student recruitments will be completed. The Centre for Arctic Medicine is arranging with partners for summer and winter courses for PhD students, first at the University of Alaska Anchorage MPH program, and then at the Summer Institute in Circumpolar Health Research in Copenhagen in May 2010 (http://sichr.circumpolarhealth. org), continuing in Oulu, November 2010, in Kautokeino, March 2011, in Oulu, June 2011, in Abisko Research Station, April 2012, and in Oulu, November 2012, and the next will be in Abisko Research Station May 2013 and Nuuk, Greenland, September 2013.

Securing the legacy of IPY 2007 2009 The overall goal of the AHHI was to increase awareness and visibility of human health concerns of Arctic peoples, foster human health research and promote health strategies that will improve health and well-being of all Arctic residents. The AHHI proved to be an effective exercise in identifying and featuring health research activities during IPY for raising the profile or Arctic human health within national governments and has highlighted the need within the Arctic Council for an ongoing emphasis, action and strategic direction for addressing critical areas of human health in the Arctic. This need was recognized during the Norwegian Arctic Council Chairmanship (20062009) and resulted in the formation in 2010 of the Arctic Human Health Expert Group (AHHEG), with professional circumpolar expertise in the areas of health systems, services and policy, social cultural and economic aspects of health, indigenous and traditional knowledge, physical and social science including behavioral and mental health and human biology, and environmental health, contaminants, and climate change (121). The AHHEG will assist the Arctic Council in better coordinating its human health activities, by: (a) Identifying priority projects that will result in improved health; (b) Engaging the appropriate subject matter experts to evaluate potential actions and collaborate on priority projects; (c) Monitoring project progress; and (d) Improving the Arctic Councils’ ability to translate knowledge gained into meaningful actions that will benefit communities, and that will result in health improvement.

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Early priorities already identified by the AHHEG include: (a) Behavioral and mental health including youth suicides; (b) Diet and nutrition with an emphasis on food security, safe water, obesity diabetes and cardiovascular diseases; (c) Health care in indigenous populations, including culturally appropriate care of the elderly; (d) Inequalities in health; and (e) The human health impacts of climate change. The importance of human health in the Arctic was again recognized on 16 February 2011, when the Government of Greenland, at the end of the Greenland/Danish Arctic Council Chairmanship, hosted the first Arctic Human Health Ministerial meeting in Nuuk, Greenland. This meeting resulted in the Arctic Health Declaration, a document signed by health ministerial representatives of the governments of Canada, Denmark, Greenland, Iceland, Norway, Sweden, the Russian Federation, the USA and the Faroe Islands (122). This declaration is intended to guide international cooperation on and national priorities for Arctic human health research and health promotion activities for many years to come. Human health is now a critical component of the Arctic Council’s sustainable development program. The AHHEG within the SDWG will continue to explore ways to ensure greater integration of human health activities, strengthen cooperation and collaborations between Arctic Council working groups and other Arctic cooperatives, and promote the translation of research into actions that will improve the health of all Arctic residents (123).

Acknowledgements Centers for Disease Control and Prevention, Arctic Investigations Program, Anchorage, Alaska; The University of Alaska, Anchorage, US; The University of Alaska, Fairbanks, US; Alaska Pacific University, Anchorage, US; The National Institutes of Health, International Relations, Fogarty International Center, Bethesda, US; The National Institutes of Health, National Library of Medicine, Bethesda, US; The US State Department, Office of Oceans Affairs, Bureau of Oceans and International Environmental and Scientific Affairs, Washington DC, US; University of Victoria, British Columbia, Canada; Environmental Health Surveillance Division, Health Canada, Ottawa, Ontario, Canada; Russian Association of Indigenous Peoples of the North (RAIPON), Moscow, Russian Federation; Gwitch’n Council International; Inuit Circumpolar Conference; Aleut International Association; Northern Forum, Secretariat, Anchorage, US; Department of Otolaryngology, Head and Neck Surgery Rigshospitalet University Hospital of Copenhagen, Denmark; Department of Public Health and General Medicine, University of Oulu, Finland; Center for International Health, University of Tromsø, Norway; Office of the Medical Officer of Health, Nuuk, Greenland; National Public Health Laboratory, Oulu, Finland; Indian and Northern Affairs



Canada; Government of Canada; Canadian IPY Secretariat; Health Canada; Government of the Northwest Territories; CIHR Team in Circumpolar Health; International Union for Circumpolar Health; International Network for Circumpolar Health Research; Alaska Native Tribal Health Consortium, Anchorage, Alaska, US; Department of Medicine, Health Sciences Center, Manitoba, Canada; Department of Public Health Sciences, Faculty of Medicine University of Toronto, Canada; Department of Epidemiology Research, Staten Serum Institute, Copenhagen, Denmark; Institute of Developmental Physiology, Russian Academy of Education, Moscow Russian Federation; Institute for Circumpolar Health Research, Institute of Physiology SB RAMS, Novosibirsk, Russian Federation; Tromsø University, Institute of Community Medicine, Tromsø, Norway; Centre for Arctic Medicine, Thule Institute, Oulu, Finland; Inuit Tapariit Kanatami, Ottawa, Canada; Arctic Net.


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Rebuilding northern foodsheds, sustainable food systems, community well-being, and food security S. Craig Gerlach1* and Philip A. Loring2 1

Center for Cross-Cultural Studies, University of Alaska Fairbanks, Fairbanks, AK, USA; 2Alaska Center for Climate Assessment and Policy, University of Alaska Fairbanks, Fairbanks, AK, USA

Background. Multiple climatic, environmental and socio-economic pressures have accumulated to the point where they interfere with the ability of remote rural Alaska Native communities to achieve food security with locally harvestable food resources. The harvest of wild foods has been the historical norm, but most Alaska Native villages are transitioning to a cash economy, with increasing reliance on industrially produced, storebought foods, and with less reliable access to and reliance on wild, country foods. While commercially available market foods provide one measure of food security, the availability and quality of market foods are subject to the vagaries and vulnerabilities of the global food system; access is dependent on one’s ability to pay, is limited to what is available on the shelves of small rural stores, and, store-bought foods do not fulfill the important roles that traditional country foods play in rural communities and cultures. Country food access is also constrained by rising prices of fuel and equipment, a federal and state regulatory framework that sometimes hinders rather than helps rural subsistence users who need to access traditional food resources, a regulatory framework that is often not responsive to changes in climate, weather and seasonality, and a shifting knowledge base in younger generations about how to effectively harvest, process and store wild foods. Objective. The general objective is to provide a framework for understanding the social, cultural, ecological and political dimensions of rural Alaska Native food security, and to provide information on the current trends in rural Alaska Native food systems. Design. This research is based on our long-term ethnographic, subsistence and food systems work in coastal and interior Alaska. This includes research about the land mammal harvest, the Yukon River and coastal fisheries, community and village gardens, small livestock production and red meat systems that are scaled appropriately to village size and capacity, and food-system intervention strategies designed to rebuild local and rural foodsheds and to restore individual and community health. Results. The contemporary cultural, economic and nutrition transition has severe consequences for the health of people and for the viability of rural communities, and in ways that are not well tracked by the conventional food security methodologies and frameworks. This article expands the discussion of food security and is premised on a holistic model that integrates the social, cultural, ecological, psychological and biomedical aspects of individual and community health. Conclusion. We propose a new direction for food-system design that prioritizes the management of placebased food portfolios above the more conventional management of individual resources, one with a commitment to as much local and regional food production and/or harvest for local and regional consumption as is possible, and to community self-reliance and health for rural Alaska Natives. Keywords: food security; Alaskan food systems; community health and well-being; food portfolios

ood security is most commonly defined as whether or not people have equitable physical and economic access to sufficient and safe foods (1). In the context that we use it here, however, food security means more than simply whether or not sufficient food is being produced or harvested in a ‘‘one-size-fits-all’’ foodto-nutrition relationship (2), and expands to include all of

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the various ways in which a food system supports health in the biophysical, social and ecological dimensions (3,4). These include the importance of culturally preferred foods, food choice, local perceptions of hunger, uncertainty and worry about food safety or food shortages, and any other psychosocial, social, cultural or environmental stresses that result from the process of putting food on


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the table. In rural, predominately Alaska Native communities, for example, wild fish and game, ‘‘country foods,’’ are important for food security, not just because they are readily available and of historical significance, but also because they are important to the preservation and transmission of traditions and cultural practices, for the maintenance of social networks and interpersonal relationships, and for supporting individual and community sense of self-worth and identity (3,5). Yet, food insecurity in Alaska and the Canadian North is a growing problem (3,6,7). According to the United States Department of Agriculture (USDA), Alaska currently has a food insecurity rate of 14.5%, lower than the nationwide average of 16% (8), although rates may be much higher for many rural communities. The non-profit group Feeding America estimates that some rural parts of the state currently experience food insecurity rates as high as 30%, with children among those most directly affected (9). One challenge in measuring food security in the North, however, is that the standardized, validated research protocols such as those used by the USDA are not necessarily appropriate for remote communities. For example, the USDA Food Insecurity protocol focuses on the availability of money to buy food, but in Alaska where subsistence foods play an important role for households in both rural and urban settings, the USDA tool does not capture this aspect well, if at all (10,11). Similarly, the USDA protocol also invokes the concept of a ‘‘balanced’’ diet, but this is confusing to many in Alaska where traditional foodways are fluid, flexible and highly seasonal in nature. Use of the word ‘‘balanced’’ might also lead some respondents to selfassess against their perceptions of government standards for nutrition, rather than in terms of their own traditions, preferences and conceptions of health.

Cultural and nutritional transitions Our research has investigated the multiple drivers and determinants of food security and insecurity in the North, and finds that, while circumstances and challenges vary from place to place, foodshed to foodshed, some general themes emerge as they connect food, livelihoods, individual and community health. Regardless of the metric chosen, indigenous peoples across the North American Arctic are ‘‘coming out of their traditional foodsheds,’’ with the use of country foods declining, and being replaced instead with market foods that, while readily available, are both expensive and generally poor in nutritional quality by comparison (1214). Consistent with this transition, people are increasingly experiencing a host of diet-related and community-based health problems, including but not limited to higher incidences of colorectal cancer, obesity and diabetes (15,16), as well as to various chronic psychological and

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psychosocial problems, such as domestic violence, alcoholism, depression and drug abuse (17). While direct causality among one or more of these dietary changes and health trends are difficult to clinically establish, the consensus among many health researchers, practitioners and local people is that solutions for these problems are best situated in local food-system reform and revitalization (18,19). Part of the challenge with respect to enhancing food security in Alaska, which we draw on as an example that no doubt has parallels to communities in Arctic Canada as well, relates to the limited capacity of the contemporary northern food production and distribution system. Despite active local food movements in many parts of Alaska (20), only an estimated 25% of agricultural products consumed in Alaska are actually produced in Alaska. Agricultural production is limited by various factors, not least of which is a paucity of farms, farmers, and in-state infrastructure for food processing and distribution (21,22). Similarly, while the commercial seafood industry is robust and thriving, providing 50% of US wild landings (23), very little of this commercial catch is marketed in Alaska, and is instead fed into national and global seafood and commodity markets. Specifics are rare regarding the quantity and origin of seafood that is actually consumed directly by Alaska Natives (21), but even in the iconic fishing communities featured in this research, most grocers do not offer a fresh seafood counter. Recently, the noticeable disparities in who benefits from Alaska’s commercial fisheries have led some to question the social justice implications of their widespread reputation of sustainability (24).

Discussion: a portfolio approach to rebuilding northern foodsheds In Alaska and elsewhere, there is no shortage of good ideas for how Northern people can enhance local and regional food security by rebuilding food systems around such values as food sovereignty and self-reliance (25). The portfolio approach to food-system design and management is a new direction that we are now exploring in ongoing research as we believe it to be relevant to the revitalization and long-term sustainability of local and regional food systems (26). Village gardens are being successfully restored to the food-system portfolio for many Alaska Native villages, especially up and down the Yukon and Tanana Rivers, and these complement rather than replace subsistence, and in so doing, diversify the food-system options and improve the food security situation. The intent of managing for a portfolio of food resources together is to foster a system with the built-in flexibility needed so that people can respond to variability and change in the availability of specific food resources,


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whether this reflects a year’s salmon return or the return of a potato or garden crop, and in ways that enhance rather than diminish local and regional food security. In other words, decisions regarding the production and marketing of food resources need to be made in a flexible, effective and regionally tailored fashion, much in the way that many indigenous societies adapt culturally to environmental variability and change through flexible subsistence calendars that incorporate multiple primary and secondary food options (27,28).

Conclusion Residents of rural Alaska who continue to engage in subsistence activities still do, to some extent, maintain a portfolio approach to food security, though their flexibility today is constrained by contemporary management approaches that focus on single-species outcomes, and by a patchwork of land tenure that severely restricts hunter and fisher flexibility when responding to change (26,29). More integrated and holistic approaches to managing wild fish and game resources that take a food-system approach should be explored. However, we also note that the portfolio approach is just one step, one that must be accompanied by a commitment to the social justice as well as to the food production and harvest aspects of the food system, and one that ensures that Alaskan Native are fed before food resources are marketed elsewhere. Otherwise, we argue, the sustainability and health of both Alaska’s local communities and their highly valued renewable food resources will remain uncertain.

Conflict of interest and funding The authors have not received any funding or benefits from industry or elsewhere to conduct this study.

References 1. WFS. Rome declaration and plan of action, World Food Summit. Rome: World Food Summit; 1996. 2. Hayes-Conroy A, Hayes-Conroy J, editors. Doing nutrition differently: critical approaches to diet and dietary intervention. Staffordshire, UK: Ashgate; in press. 3. Loring PA, Gerlach SC. Food, culture, and human health in Alaska: an integrative health approach to food security. Environ Sci Policy. 2009;12:46678. 4. Fazzino DV, Loring PA. Nutritional and cultural transitions in Alaska Native food systems: legacies of colonialism, contested innovation, and ruralurban linkages. In: Hayes-Conroy A, Hayes-Conroy J, editors. Doing nutrition differently: critical approaches to diet and dietary intervention. Staffordshire, UK: Ashgate; in press. 5. Fienup-Riordan A. Hunting tradition in a changing world: Yup’Ik lives in Alaska today. Rutgers, New Jersey: Rutgers University Press; 2000. 6. Caulfield R. Food security in Arctic Alaska: a preliminary assessment. Sustainable food security in the Arctic. Alberta, Canada: CCI Press; 2002.

7. Egeland GM, Pacey A, Cao Z, Sobol I. Food insecurity among Inuit preschoolers: Nunavut Inuit Child Health Survey, 2007 2008. CMAJ. 2010;182:2438. 8. USDA. Household food security in the United States, 2010. Washington, DC: United States Department of Agriculture, Economic Research Service; 2011. Report No.: ERR-125. Available from: http://www.ers.usda.gov/publications/err125/ 9. Feeding America. Map the meal gap, food insecurity estimates at the county level. 2011 [cited 2011 Dec 3]. Available from: http://feedingamerica.org/hunger-in-america/hunger-studies/ map-the-meal-gap.aspx 10. Bersamin A, Sidenberg-Cherr S, Stern JS, Luick BR. Nutrient intakes are associated with adherence to a traditional diet among Yup’ik Eskimos living in remote Alaska Native communities: the CANHR Study. Int J Circumpolar Health. 2007;66:6270. 11. Fazzino D, Loring PA. From crisis to cumulative effects: food security challenges in Alaska. NAPA Bulletin. 2009;32:15277. 12. Kuhnlein HV, Receveur O, Soueida R, Egeland GM. Arctic indigenous peoples experience the nutrition transition with changing dietary patterns and obesity. J Nutr. 2004;134: 144753. 13. Loring PA. Coming out of the foodshed: change and innovation in rural Alaskan food systems. Fairbanks, AK: University of Alaska Fairbanks; 2007. 14. Bersamin A, Luick BR, Ruppert E, Stern JS, Sidenberg-Cherr S. Diet quality among Yup’ik eskimos living in rural communities is low: the center for Alaska Native Health Research Pilot Study. J Am Diet Assoc. 2007;106:105563. 15. Fenaughty AM, Fink C, Peck D, Wells RS, Utermohle CJ, Peterson E. The burden of overweight and obesity in Alaska. Anchorage, AK: Section of Chronic Disease Prevention and Health Promotion, Division of Public Health, Alaska Department of Health and Social Services; 2010. Available from: http://dhss.alaska.gov/dph/Chronic/Documents/Obesity/pubs/ ObesityBurdenReport_2010.pdf 16. McLaughlin JB, Middaugh JP, Utermohle CJ, Asay ED, Fenaughty AM, Eberhardt-Phillips JE. Changing patterns of risk factors and mortality for coronary heart disease among Alaska Natives. JAMA. 2004;291:25456. 17. AKDHSS. Moving forward, comprehensive integrated mental health plan 20062011. Anchorage, AK: Alaska Department of Health and Social Services; 2011. Available from: http:// dhss.alaska.gov/dph/HealthPlanning/Pages/movingforward/ execsumm.aspx 18. Kuhnlein H, Erasmus B, Creed-Kanashiro H, Englberger L, Okeke C, Turner N, et al. Indigenous peoples’ food systems for health: finding interventions that work. Public Health Nutr. 2007;9:1013. 19. Hassel CA. Woodlands Wisdom: a nutrition program interfacing indigenous and biomedical epistemologies. J Nutr Educ Behav. 2006;38:11420. 20. Garcia RA. Public use of local foods in the Tanana Valley: understandings of producers and low-income community members. Fairbanks, AK: University of Alaska Fairbanks; 2012. 21. Hanna V, Frazier R, Parker K, Ikatova I. Food system assessment. Anchorage, AK: Institute of Social and Economic Research, University of Alaska Anchorage; 2012. 92 p. 22. Paragi T, Gerlach SC, Meadow A. Security of red meat supply in Alaska. Agroborealis. 2010;41:367. 23. NMFS. Fisheries of the United States. Silver Spring, MD: National Marine Fisheries Service, Office of Science and Technology; 2010. 14 p. Report No.: Current Fishery Statistics No. 2010.


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24. Loring PA. Alternative perspectives on the sustainability of Alaska’s commercial fisheries. Conserv Biol. 2013;27:5563. 25. Gerlach SC, Loring PA. Rebuilding Alaska foodsheds: no shortage of good ideas. Rural Connections. 2012;6:234. 26. Loring PA, Gerlach SC. Food security and conservation of Yukon River Salmon: are we asking too much of the Yukon River? Sustainability. 2010;2:296587. 27. Williams N, Hunn E, editors. Resource managers: North American and Australian hunter-gatherers. AAAS selected symposium 67. Boulder, CO: Westview Press; 1982. 28. Loring PA, Gerlach SC. Outpost gardening in interior Alaska: food system innovation and the Alaska native gardens of the 1930s through the 1970s. Ethnohistory. 2010;57:18399.

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29. Loring PA, Chapin III FS, Gerlach SC. Ecosystem services and the services-oriented architecture: computational thinking for the diagnosis of change in social ecological systems. Ecosystems. 2008;11:47889. *S. Craig Gerlach Center For Cross-Cultural Studies University of Alaska Fairbanks Fairbanks, AK 99712 USA Tel: (907) 474-6752 Email: [email protected]



Perceptions of needs regarding FASD across the province of British Columbia, Canada Anne George*, Cindy Hardy and Erica Clark Department of Pediatrics, University of British Columbia, Prince George, BC, Canada

Introduction Considerable activity exists to address foetal alcohol spectrum disorder (FASD) across the province of British Columbia (BC), Canada. This includes a provincial government public awareness campaign launched in Fall 2011, provincial-wide diagnostic services, a provincial program providing support for families who are going through the assessment processes, a teacher education program, parent peer support programs and research. In addition, the provincial government has written a 10-year plan of action (1). In 2006, the provincial government established the FASD Action Fund (2) with $7 million supporting demonstration projects conducted by organizations across BC. We conducted the current study as part of an overall evaluation of the FASD Action Fund (3). The objective of this current study was to describe perceived needs for services for people affected by FASD in rural and urban BC using thematic analysis of proposals submitted for funding to the Victoria Foundation’s FASD Action Fund.

c. Training: Intensive training designed to raise knowledge and skill level (e.g. neurobehavioral training about FASD; specific intervention skills). d. Resource Development: Creation of resources about FASD (e.g. libraries or resource rooms; tools for education about FASD). e. Education: Short-term training designed to raise awareness about FASD (e.g. workshops and community meetings). f. Transitions: Supports for people with FASD and their families during significant life transitions (e.g. from school to employment; from incarceration to community). g. Peer Support: Activities and events where individuals with FASD support others with FASD (e.g. addictions recovery group). h. Research: Research projects focused on FASD (e.g. exercise as a strengths-based intervention; mentoring teachers). i. Other: Residual category used to code other activities (e.g. assessment teams; creation of networks of professionals or families).

Methods We analyzed the 110 proposals submitted to the FASD Action Fund according to the submitting agency’s community size and the project focus. Two researchers independently coded the proposals along these dimensions and any disagreements were resolved by consensus. Each proposal could have multiple codes for topic. Nine themes emerged from the content analysis, as follows. a. Skill development: Help people with FASD develop skills (e.g. life skills, social skills, parenting skills, employment skills). b. Care: Direct services to people with FASD (e.g. dayto-day mentoring and support for young adults with FASD).

Results Of the 110 proposals submitted, 32 (29.1%) were from rural or small town communities with populations less than 10,000, 26 (23.6%) from small cities, 38 (34.5%) from metropolitan areas and 14 (12.7%) from agencies working with networks of communities of various sizes. The most common types of needs expressed were for direct services for people with FASD. Skill development for people affected by FASD was also a common theme, as was awareness raising education. Development of resources such as cultural camps, libraries or curriculum development was frequently proposed. Analysis of themes by community size revealed that proposals from rural and small town communities emphasized care (i.e. direct services), skill development,

Poster presented at International Congress on Circumpolar Health 15 (ICCH15), held at Fairbanks, Alaska, August, 2012.


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awareness raising education, and development of resources. Compared to proposals from larger communities or networks of communities, proposals from rural and small town communities were more likely to focus on awareness raising education.

Discussion In BC, there is widespread interest and increasing expertise in the area of FASD. The FASD Action Fund resulted in a robust response to call for proposals from across the province (population 4 million). Perceived needs for supporting people with FASD in BC include directly caring for affected people, developing the skills of people with FASD and their caregivers, and developing community education, networking and material resources.

References 1. British Columbia. Ministry of children and family services. Fetal alcohol spectrum disorder: building on strengths. A provincial plan for British Columbia 20082018. [cited 2013 Jun 26]. Available from: http://www.mcf.gov.bc.ca/fasd/ten_ year_plan.htm. 2. Victoria Foundation. Fetal Alcohol Spectrum Disorder (FASD) Action Fund. [cited 2013 Jun 26]. Available from: http://www. victoriafoundation.bc.ca/fetal-alcohol-spectrum-disorder-fasdaction-fund. 3. George A, Hardy C, Clark E, Tu A, Fetterly C. Evaluation of the Victoria Foundation $7M. Fetal Alcohol Spectrum Disorder (FASD) Action Fund. Victoria, BC: Report for the Victoria Foundation; 2012. Available from: http://www.victoriafoundation. bc.ca/news/fasd-action-fund-evaluation-complete *Anne George Email: [email protected]

Acknowledgements This project was funded by the Victoria Foundation, Victoria, British Columbia, Canada.

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The Nuka System of Care: improving health through ownership and relationships Katherine Gottlieb* Southcentral Foundation, Anchorage, AK, USA

Southcentral Foundation’s Nuka System of Care, based in Anchorage, Alaska, is a result of a customerdriven overhaul of what was previously a bureaucratic system centrally controlled by the Indian Health Service. Alaska Native people are in control as the ‘‘customer-owners’’ of this health care system. The vision and mission focus on physical, mental, emotional, and spiritual wellness and working together as a Native Community. Coupled with operational principles based on relationships, core concepts and key points, this framework has fostered an environment for creativity, innovation and continuous quality improvement. Alaska Native people have received national and international recognition for their work and have set high standards for performance excellence, community engagement, and overall impact on population health. In this article, the health care transformation led by Alaska Native people is described and the benefits and results of customer ownership and the relationship-based Nuka System of Care are discussed. Keywords: Alaska Native; wellness; self-determination; relationships; outreach; public health; quality improvement

outhcentral Foundation is a non-profit health care organization serving more than 60,000 Alaska Native and American Indian people in Southcentral Alaska. It was established in 1982 under the tribal authority of Cook Inlet Region Inc. (CIRI), one of the Alaska Native regional corporations created by Congress in 1971 under the terms of the Alaska Native Claims Settlement Act. CIRI established Southcentral Foundation to improve the health and social conditions of Alaska Native people, enhance culture and empower individuals and families to take charge of their lives. Southcentral Foundation’s ‘‘Nuka System of Care’’ is a term that describes the entire health care system created, managed and owned by Alaska Native people to achieve physical, mental, emotional and spiritual wellness. It is inclusive of all parts of the organization including behavioral, dental, medical and traditional services and all the systems, processes and departments supporting the service delivery.

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History Over the last 3 decades, Southcentral Foundation’s workforce has grown from fewer than 25 to more than 1,500 employees and the operating budget from $3

million to $210 million. This growth can be attributed in large part to a change in ownership of the Alaska Native health care system from government control to ‘‘customer ownership.’’ For 50 years, Alaska Native people in Southcentral Alaska received their health care as ‘‘beneficiaries’’ of the Indian Health Service’s Native hospital. Employees were not able to be creative or innovative because it was a large, bureaucratic system centrally controlled from Washington, DC, 5,000 miles away. Patients waited weeks to get an appointment or accessed the system through the emergency room, and saw different providers each time. There was a disconnect between care for the mind and care for the body. Departments and programs acted independently. Patients were not happy and employees were not happy. Health statistics were bleak. Many patients left the Alaska Native system altogether to find better care (1). Then, in response to Alaska Native and American Indian people advocating for a voice in program planning and service delivery, Congress passed a federal law in favor of self-determination (2,3). This legislation opened the door for tribes to choose ownership over the entities delivering the services. The Alaska Native leadership of Southcentral Foundation also saw


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this as an opportunity for innovation to completely redesign the tribal health care system in Southcentral Alaska based on Alaska Native values and needs. The administration and Southcentral Foundation partnered to survey the Native Community and find out what was desired. By 1999, Alaska Native people were no longer ‘‘beneficiaries’’ of a government-run system, but, rather, chose to become self-determined ‘‘customers’’ and also ‘‘owners’’ of their tribally managed health care. This meant that Alaska Native people were no longer mere recipients of services, but, rather, in control of decision-making and administration. Along with this new customer-owner status came responsibilities to make informed choices on priorities for the health care system and to work to sustain it for future generations; what followed was a customerdriven overhaul of health care delivery, philosophy and values. As a result, Southcentral Foundation has today what is known as its Nuka System of Care. It addresses the challenges that health care systems around the world face how to improve health care outcomes and customer satisfaction without skyrocketing costs.

Vision Statement A Native Community that enjoys physical, mental, emotional and spiritual wellness.

Shared vision and mission Southcentral Foundation’s vision is ‘‘A Native Community that enjoys physical, mental, emotional and spiritual wellness.’’ The organization is committed to doing more than just providing treatment and health education. Southcentral Foundation’s barometer for success is whether the population served is able to truly experience multidimensional wellness, and if improvements in wellness are experienced from one generation to the next. The mission statement emphasizes getting there by working with (not doing ‘‘to’’ or ‘‘for’’) the Native Community. The aim is a Native Community that is renowned for being healthy. Southcentral Foundation measures its progress through a robust data collection effort, benchmarking with other high-performing health care organizations around the country and tracking health disparity data at the local, state and national levels. Southcentral Foundation is intentional in the way it communicates its mission and vision to the community, workforce and customer-owners. The vision and mission provide guidance and consistency; there is a clear message and path to follow. All corporate, division, work unit, and individual goals and objectives flow out of the vision and mission’s 3 ‘‘key points’’: shared responsibility, commitment to quality and family wellness. This framework, established by the Alaska Native board of directors, keeps Southcentral Foundation’s performance evaluation and improvement efforts focused on achievement of the vision and mission. The governing board, which is

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composed entirely of customer-owners, sets the direction and the president/CEO creates an environment that ensures the entire workforce can both stay the course and measure progress along the way. As a result, Southcentral Foundation’s data analysis and tracking ties directly back into fulfillment of the vision and mission, and achievements are shared with stakeholders in a meaningful way. For example, under the corporate goal of ‘‘shared responsibility’’ there are 3 corporate objectives one of which is ‘‘achieve excellence in customer-owner satisfaction.’’ Knowing that appointment access is a key driver of customer-owner satisfaction, departments created work plans and measurement targets around improving the availability of appointments. The data collection approach included tracking average appointment availability at 8:00 am daily, the ‘‘third next available appointment’’ less than 5 days out, as well as the medians and other subreports. These operational measures are available on a centralized ‘‘data mall’’ and are segmented to the appropriate level to support improvement of day-to-day work processes.

Mission Statement Working together with the Native Community to achieve wellness through health and related services.

Key Points Shared Responsibility We value working together with the individual, the family, and the community. We strive to honor the dignity of every individual. We see the journey to wellness being traveled in shared responsibility and partnership with those for whom we provide services. Commitment to Quality We strive to provide the best services for the Native Community. We employ fully qualified staff in all positions and we commit ourselves to recruiting and training Native staff to meet this need. We structure our organization to optimize the skills and contributions of our staff. Family Wellness We value the family as the heart of the Native Community. We work to promote wellness that goes beyond absence of illness and prevention of disease. We encourage physical, mental, social, spiritual & economic wellness in the individual, the family, the community and the world in which we live.


The Nuka System of Care

Service delivery

Relationships

To achieve its vision, Southcentral Foundation provides a wide range of behavioral, dental, medical and community services. These services include primary care, both in outpatient and home settings; dentistry; outpatient behavioral health; residential behavioral health; traditional healing; complementary medicine; health education and more. In addition, Southcentral Foundation has administrative programs that support direct service delivery, including human resources, information technology, compliance, grants, public relations, finance, facilities and quality assurance. In general, Southcentral Foundation’s services are provided ‘‘prepaid,’’ based on legislative agreements and funding requirements, to members of 227 federally recognized Alaska Native tribes who live in Anchorage, the Matanuska-Susitna Valley and 55 rural Anchorage Service Unit villages. This 108,000-square-mile service area stretches about 2,000 miles from west to east, in a state that is nearly 3 times the size of Texas. As significant numbers of Alaska Native people continue to migrate out of Alaska’s rural areas to the urban centers (4), most customer-owners live in or near Anchorage, home of the Alaska Native Medical Center’s 150-bed hospital and the Anchorage Native Primary Care Center, and other Southcentral Foundation owned and co-owned facilities and services. Care delivery mechanisms include ambulatory office visits, home visits, email and telephone visits, health information and education via classes and mixed media, inpatient hospital services, day and residential treatment, as well as consultation with and referral to higher levels of care. Southcentral Foundation also jointly owns and manages the Anchorage-based Alaska Native Medical Center with the Alaska Native Tribal Health Consortium (ANTHC). When advanced and complex care is required, Southcentral Foundation engages a seamless continuum of care by working in partnership with the tertiary and specialty Medical Services Division of ANTHC. Southcentral Foundation also has experience in distance delivery of health care. Southcentral Foundation’s clinical teams regularly travel to villages off the road system accessible only by air or boat to deliver family medicine, behavioral health, dental and optometry services. Where village clinics are in place, Southcentral Foundation clinicians also make use of electronic communication, including state-of-the-art telemedicine technology, to consult on assessment and treatment. In some cases, appropriate treatment requires Southcentral Foundation to bring customer-owners from the rural communities to Anchorage.

Southcentral Foundation’s Nuka System of Care is based on what customer-owners really want a primary focus on building and maintaining relationships. Research findings have shown that relationship-based partnerships, over time, have the power to influence health outcomes (510). In the Nuka System of Care, one of the chief responsibilities of each provider is to work with customer-owners to establish trusting, accountable and long-term relationships. Relationships provide a better understanding of the context in which a customer lives. As a result, providers are in a better position to understand symptoms, answer questions, have meaningful conversations about risks and benefits, and work with each customer to make better health decisions. These basic principles are consistently put into practice by Southcentral Foundation’s medical, behavioral, dental and traditional service providers. However, the focus is not only on building relationships between providers and customer-owners. Southcentral Foundation’s operational principles, which spell out ‘‘R-E-L-A-T-I-O-N-S-H-I-P-S,’’ influence everything from the strategic planning process to employee hiring practices, facility design, job progressions, information support, quality improvement, financing structures, work flow across boundaries and more. Strong and effective relationships are necessary across the organization to accomplish goals, objectives and work plans. Building a culture of trust, based on relationships, encourages shared decision-making and supports innovation and creativity. The organization’s executive leaders role model relationship-building behaviors for the rest of the workforce, including sharing personal stories, inviting inquiry and questions, admitting mistakes and celebrating successes. A 3-day mandatory Core Concepts training, led by the president/CEO, helps employees understand how their relational styles impact others, how their experiences affect how they approach and build relationships, and how to articulate and respond to story in everyday work and life. Southcentral Foundation also depends on relationships with national, regional and local partners. The focus is more on collaboration than competition. As a result, service gaps are identified and new collaborations emerge each year. Over a decade of performance measurement data has shown that the relationship-based Nuka System of Care has effectively broken down barriers including barriers of space, attitude, language and time that previously stood in the way of better health and wellness.


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Operational Principles Relationships between the customer-owner, the family, and provider must be fostered and supported Emphasis on wellness of the whole person, family, and community including physical, mental, emotional, and spiritual wellness Locations that are convenient for the customerowner and create minimal stops for the customerowner Access is optimized and waiting times are limited Together with the customer-owner as an active partner Intentional whole system design to maximize coordination and minimize duplication Outcome and process measures to continuously evaluate and improve Not complicated but simple and easy to use Services are financially sustainable and viable Hub of the system is the family Interests of the customer-owner drive the system to determine what we do and how we do it Population-based systems and services Services and systems build on the strengths of Alaska Native cultures

Core Concepts Work together in relationship to learn and grow Encourage understanding Listen with an open mind Laugh and enjoy humor throughout the day Notice the dignity and value of ourselves and others Engage others with compassion Share our stories and our hearts Strive to honor and respect ourselves and others

Customer ownership The shift to customer ownership, including the involvement of Alaska Native people in the design, implementation and control of their own programs, has produced dramatic changes in the delivery of health care services, in Alaska Native people’s sense of self-efficacy, and ultimately, in health outcomes. With customer-owners originating from more than 200 tribes in Alaska alone, Southcentral Foundation works in partnership with many different cultural groups. To ensure the organization is capturing feedback from this diverse customer base, it offers a range of options for customer-owners to be heard and responded to some examples include personal interaction with staff, comment cards, special events, surveys, a 24-h telephone hotline and online form, focus groups and advisory committees. Southcentral Foundation’s board of directors and advisory boards are comprised solely of Alaska Native

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customer-owners, representing a number of different tribes. Customer-owners have also established careers at Southcentral Foundation in an increasing number of both clinical and non-clinical roles. The majority of the workforce is, in fact, Alaska Native and American Indian, including the long-time president/chief executive officer, 2 vice presidents, and over 60% of the organization’s managers. Internship programs, succession planning and other workforce development initiatives are continuously grooming the next generation to take over paraprofessional, professional and leadership roles within the organization. Alaska Native and American Indian employees also have an active role as members of Southcentral Foundation’s 4 functional committees process improvement, quality improvement, quality assurance and operations. The committees were created to be responsive to customer-owner feedback and move improvement initiatives and work plans forward without having to take ideas to the executive leadership team. The relationship-based operational principles are used to measure the alignment of any specific improvement idea. Any idea from an employee or customer-owner using the system can be put forward, and, if there is good alignment with the principles, an effort will be made to support testing that idea. Before the Nuka System of Care, far too many Alaska Native people believed that they had no control or opportunity for input. This belief was conditioned over many decades of well-intended government-run health care that promoted the message ‘‘we will take care of you.’’ To reverse this took a concentrated effort and empowerment on many different levels. While the system is not perfect, there have been measurable improvements. For example, a recent yearlong survey asking customerowners about their experiences in Southcentral Foundation’s clinics showed that 98.5% of the respondents agreed with the following statement: ‘‘I was given the chance to provide input into decisions about my health care.’’ Another example lower scores in the ‘‘Wait time to be seen by my provider’’ survey question initiated improvement efforts to make same-day access a priority. The Nuka System of Care is a departure from ‘‘beneficiaries’’ or ‘‘patients’’ serving as mere recipients of tests, diagnoses, and pills. Instead, customer-owners actively share responsibility for the success of the health care system and for their family’s health and wellness.

Results The keys to Southcentral Foundation’s improvement journey and resulting success can be distilled down to: (a) customer ownership and (b) relationships. Health care leaders from around the world attend Southcentral Foundation’s annual Nuka System of Care Conference to learn more about these approaches, including how they


The Nuka System of Care

lead to the implementation of best practices such as organization-wide ‘‘advanced access,’’ utilization of data and measurement, integrated care teams and integration of behavioral health and traditional healing into primary care. The relationship-based, customer-owned Nuka System of Care has helped Southcentral Foundation outperform many known health care systems. It works because Southcentral Foundation redesigned the entire health care system based on the wants and wishes of its customerowners, and, in doing so, empowered those receiving the services to share responsibility. The results include the following:

. Prior to 1996, there was no direct primary care access. In 1996, only 35% of the local Alaska Native population had a designated primary care provider. Of those, 43% did not know who that provider was. Now, more than 95% are empanelled to an integrated primary care team. Providers know their customers’ names, as well as their histories, preferences and family dynamics. . Before Nuka, the average delay to schedule a routine appointment was 4 weeks. Now, Southcentral Foundation offers same-day access, in person or by phone or email (customer’s choice). . By implementing same-day access, Southcentral Foundation reduced the number of individuals on its behavioral health wait list (backlog) from about 1,300 to nearly zero in a year. . Phone wait times, before Nuka, were in excess of 2 min, and are now limited to less than 30 s. . A 36% reduction in hospital days, 42% reduction in ER and urgent care usage, and 58% reduction in specialty clinic visits have been sustained for 10 and above years. . In 75% of the HEDIS measures (national standards), Southcentral Foundation is in the 75th percentile or better, and for many, like diabetes care, in the 95th percentile. . Staff turnover is one-fourth of the level it was 5 years earlier. . 25% increase in childhood immunizations. . Customer satisfaction with respect for their cultures and traditions at 94%. Southcentral Foundation has distinguished itself as a role model health care organization. It was Alaska’s first health care organization, and 15th health care organization in the nation, to receive the Malcolm Baldrige National Quality Award. The US Congress created this award program in 1987 to identify and recognize the country’s most innovative organizations, and then disseminate and share best-practice performance strategies. Southcentral Foundation also achieved the highest level

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of Patient Centered Medical Home recognition from the National Committee for Quality Assurance in 2009. The Patient Centered Medical Home standards emphasize the use of systematic, patient-centered, coordinated care that supports access, communication and patient involvement. Southcentral Foundation believes these standards could be improved by focusing on: the individual (in Southcentral Foundation’s case, the ‘‘customerowner’’) and his/her family driving the system rather than the professionals; services that are woven into customers’ lives built around them, rather than the medical office; and an approach that addresses the whole person and family in a well-coordinated and personal way. A better term for the Patient Centered Medical Home designation might be ‘‘customer-driven whole person care’’ or ‘‘customer- and family-driven integrated care provided on their terms.’’ Southcentral Foundation’s customer-owners recognize that future generations of their families will continue to own, manage and benefit from these services. With this ownership, comes a sense of shared responsibility for the health care system’s success. The people of the region are working to continuously improve the services and ensure that the decisions made are in alignment with their needs and values. Consistent with the body of knowledge on community readiness (11), by being involved, Alaska Native people are now more aware of health promotion and disease prevention options and are more interested and willing to make changes. The value put on relationships in this Alaska Nativeowned system of care provides a dramatically different care experience than what was encountered when the health system was under government control. Better relationships have meant not only healthier customerowners, but also healthier employees and a healthier organization. These outcomes continue to attract health care professionals and government leaders from all over the world who travel far north to Alaska to learn more.


References 1. Dixon M, Shelton BL, Roubideaux Y, Mather D, Smith CM. Tribal perspectives on Indian self-determination and selfgovernance in health care management. Denver, CO: National Indian Health Board; 1998, p. 78. 2. The Indian Self-Determination and Education Assistance Act, Pub. L. No. 93638, 88 Stat. 2203. 3. Cornell S, Kalt JP. American Indian self-determination: the political economy of a policy that works. HKS Faculty Research Working Paper Series RWP10-043, Cambridge, Mass: John F. Kennedy School of Government, Harvard University; 2010.


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4. Martin S, Killorin M, Steve Colt. Fuel costs, migration, and community viability. Institute of Social and Economic Research, University of Alaska Anchorage; 2008. 5. Stewart MA. Effective physicianpatient communication and health outcomes: a review. CMAJ. 1995;152:142333. 6. Stewart M, Brown JB, Boon H, Galajda J, Meredith L, Sangster M. Evidence on patientdoctor communication. Cancer Prev Control. 1999;3:2530. 7. Di Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health outcomes: a systematic review. Lancet. 2001;357:75762. 8. Barry CA, Bradley CP, Britten N, Stevenson FA, Barber N. Patients’ unvoiced agendas in general practice consultations: qualitative study. BMJ. 2000;320:124650. 9. Platt FW, Gaspar DL, Coulehan JL, Fox L, Adler AJ, Weston WW, et al. ‘‘Tell me about yourself’’: the patient-centered interview. Ann Intern Med. 2001;134:107985.

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10. Frosch DL, Kaplan RM. Shared decision making in clinical medicine: past research and future directions. Am J Prev Med. 1999;17:28594. 11. Edwards RW, Jumper-Thurman P, Plested BA, Oetting ER, Swanson L. Community readiness: research to practice. J Community Psychol. 2000;28:291307. *Katherine Gottlieb President/CEO Southcentral Foundation 4501 Diplomacy Drive Anchorage, AK 99508 USA Email: [email protected]



Lots to lose: reversing the obesity epidemic Ward B. Hurlburt* Chief Medical Officer, Department of Health and Social Services, State of Alaska, Anchorage, AK, USA

he complications of obesity and overweight are the predominant public health challenges for the United States and for most of the countries of the industrialized world for the 21st century. The worldwide obesity rate has more than doubled since 1980 and continues to increase. In the United States, the most rapidly growing cohort consists of those persons who are considered ‘‘massively obese,’’ defined as having a body mass index (BMI) of more than 40. As determined by the self-reported US Behavioral Risk Factor Surveillance System (BRFSS), two-thirds of adults in the United States are overweight or obese. Overweight and obese are defined as having a BMI of 25 or more and 30 or more, respectively. As determined by the US National Health and Nutrition Examination Survey (NHANES), which is based on actual height and weight measurements, 74% of adults in the United States are overweight or obese (1). The White House report which is focused on solving the problem of childhood obesity within a generation sponsored by First Lady Michelle Obama states that, due to the complications of overweight and obesity, children in the United States being born this century may be the first generation of Americans to live a shorter life span than their parents since the country was founded in 1776 (2). It was projected that the average American would consumes 22 hot dogs during the summer months from 1 July through to American Labour Day, and that the average American consumes about 50 gallons of sugarsweetened beverages each year. The Organization for Economic Cooperation and Development (OECD) reported that in 2008, of its member countries, the United States had the highest rate of obesity with 34% of adults having a BMI of 30 or more (3). The average obesity rate for adults in the 33 member OECD countries was 16%. With the exception of Mexico, 6 of the 7 nations with the highest rates of obesity were predominantly English speaking countries. The self-image of Americans is often at variance with the reality of their BMI. According to the September 2010 Harris Interactive/Health Day Survey, 30% of overweight Americans believe they are of normal weight,

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70% of obese Americans believe they are simply a little overweight, and 60% of massively obese (BMI 40 or a BMI 35 with co-morbidities) Americans believe they are merely overweight (4). As reported in the New England Journal of Medicine in December 2010, 19 studies followed groups of American females aged 528 years. This review found that non-smoking females with a BMI of 22.524.9 had the lowest death rates, overweight females experienced a 13% death rate increase, obese females experienced a 4488% death rate increase, and morbidly obese females experienced a death rate increase of 250%. The analysis of male death rate experience was comparable (5). More than one-quarter of Americans aged 1724 years who are potentially interested in joining the US Armed Forces are found to be unqualified due to an excessive BMI. For Americans who successfully enter on active duty, the Department of Defense continually faces a comparable problem of maintaining a healthy BMI. The Journal of the American Medical Association reported a CDC study in 2003 that projected that 38% of American females being born this century face a 38.5% lifetime risk of developing diabetes. For males, the risk was stated to be 32.8%. For Hispanics in the United States, the risks were stated to be 52.5 and 45.4% for females and males, respectively. The medical complications of overweight and obesity are now reported to cause 365,000 premature deaths a year in the United States, a larger number than those due to any other underlying cause except tobacco use. Diabetes is the most frequent cause of these premature deaths. By way of comparison, the 20092010 H1N1 novel influenza epidemic in the United States caused 1642 premature deaths and HIV/AIDS caused about 15,000 deaths annually. In 2010, the medical care costs for Alaska attributable to obesity and overweight were $459 million, which exceeded Alaska’s tobacco-related 2010 medical care costs of $380 million. Increasing rates of overweight and obesity are problems from infancy onwards. Many children enter kindergarten already overweight or obese. Most of these


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children remain at an unhealthy weight as they age, and with each grade, they are joined by increasing numbers of overweight and obese peers. Not only is obesity associated with poor health outcomes in adults, it is also associated with poor health outcomes in childhood. We have also seen that childhood obesity is associated with poorer academic performance in school, lower teacher ratings of social/emotional well being, and increased absenteeism. Conversely, improved nutrition and physical activity among school children are associated with improved academic test scores, improved attendance, and better class participation. Eighty percent of overweight/obese 1015 year olds were still overweight or obese at age 25. Overweight and obese adults have increased risks of heart disease, diabetes, several cancers, oesophageal reflux, gall stones, fatty liver disease and cirrhosis, kidney stones, kidney failure, osteoarthritis, back problems, sleep apnea, pulmonary embolism, high risk pregnancies, menstrual irregularity, and infertility. With the leadership and commitment of their school boards and school district superintendents, two of Alaska’s largest school districts (Matanuska-Susitna Borough and Anchorage) embarked on programs to remove sugar-sweetened beverage vending machines from their schools, to improve the nutritional quality of their school breakfasts and lunches, and to increase school hours devoted to physical education and recess physical activities. While the results have not been dramatic to date, both school districts reported a modest but statistically significant decrease in the prevalence of overweight and obesity (as measured by a BMI ] 85th percentile) for Grades K 12, comparing the 20022003 to the 20102011 school years. Opportunities to reduce the prevalence of obesity and overweight are present from the earliest days of a baby’s life. It has been demonstrated that babies who are breastfed for 612 months are more likely to maintain a healthy BMI throughout their lives. Like most western US states, the rates for initiation of breast-feeding of Alaska babies is quite good. However, the rate of persistence of breastfeeding is poor. An increased work demand on parents has resulted in families eating more calorie-laden restaurant and prepared foods. The increased availability of television programs and video games has greatly increased the amount of screen time for Americans of all ages. In some neighbourhoods, safety issues that formerly were less of a concern sometimes result in conscientious parents limiting the freedom their children have to go outside to play. Falling school academic test results in the United States compared to other nations has resulted in a reduction of time allocated to non-academic teaching, such as time available for physical education classes. Busy parents, often with long commutes, find so-called ‘‘fast foods’’ to

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be convenient, tasty, and often economical. With increased American affluence and heavy marketing, sugarsweetened beverages have become a daily staple as opposed to an occasional treat. Portion sizes for such drinks have increased from 6 ounces to 12 or 20 ounces. Some ethnic groups often report consumption of several of the larger portions of sugar-sweetened beverages each day. A number of experts believe that if there is 1 ‘‘villain’’ to be identified in the steady increase in calorie consumption by Americans, it is sugar-sweetened beverages. Overweight and obesity and their medical complications is the dominant public health challenge we face in Alaska and in the United States currently and, I believe, will be so for the rest of this young century. Attitudes are evolving, but to date it has often been challenging to achieve political acceptance that this is a public health problem despite the fact that the medical costs of caring for the complications of an excess BMI impact all governments and all members of society. The response is often ‘‘why should this be a function of government?’’ ‘‘Why don’t people just make better choices and push themselves away from the table?’’ While there are clear differences between this challenge and the tobacco prevention story, I believe there are many lessons to be learned. It did take decades of public education to bring about a societal change in both norms of behavior and in the acceptance of the appropriateness of community action. Our anti-tobacco efforts will still take decades to reach achievable levels of non-use and reduced medical complications. Reducing overweight and obesity and its medical complications will be even more challenging. The recent experience in 2 Alaska school districts suggests that societal efforts can result in reducing the prevalence of this public health challenge.

References 1. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 19992010. J Am Med Assoc. 2012;307:4917. 2. White House Task Force on Childhood Obesity Report to the President February 2011. [cited 2013 Jun 26]. Available from: http://www.letsmove.gov/white-house-task-force-childhoodobesity-report-president. 3. Organization for Economic Co-operation and Development, Obesity Update 2012. [cited 2013 Jun 26]. Available from: www. oecd.org/health/healthpoliciesanddata/49716427.pdf 4. Harris Polls, September 2, 2010. [cited 2013 Jun 26]. Available from: www.harrisinteractive.com/NewsRoom/HarrisPolls/tabid/ 447/mid/1508/. 5. Berrington de Gonzalez A, Hartge P, Cerhan JR, Flint AJ, Hannan L, MacInnis RJ, et al. Body-mass index and mortality among 1.46 million white adults. N Engl J Med. 2010;363: 22119. *Ward B. Hurlburt Email: [email protected]



HPV vaccines for circumpolar health: summary of plenary session, ‘‘Opportunities for Prevention: Global HPV Vaccine’’ and ‘‘Human Papillomavirus Prevention: The Nordic Experience’’ Eileen F. Dunne1* and Anders Koch2 1

Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Atlanta, GA, USA; 2Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark

In this publication, we provide an overview of the presentations, ‘‘Opportunities for Prevention: Global HPV Vaccine’’ and ‘‘Human Papillomavirus Prevention: The Nordic Experience’’ as a part of the 15th International Congress on Circumpolar Health, held at Anchorage, Alaska, on August 8, 2012. We provide an overview of HPV, HPV vaccines and policy as well as the Nordic experience with HPV vaccine introduction. Keywords: HPV vaccine; Nordic countries; circumpolar health; HPV

uman papillomavirus (HPV) is a common infection and is species specific. There are more than 100 HPV types, 40 of which infect the mucosa, including the genital mucosa. The virus is composed of outer capsid proteins (L1 and L2), enclosing a small 8kilobyte double-stranded, circular DNA. The capsid proteins will self-assemble into empty capsid shells when produced in a cell culture. These empty capsid shells, or virus-like particles (VLPs), resemble a wild-type virus but contain no infectious material. This unique property of the capsid proteins was essential for vaccine development as the proteins provide an antigen with conformational epitopes. Animal models were fortunately available to facilitate vaccine development. Production of bovine papillomavirus VLPs and cottontail rabbit papillomavirus VLPs demonstrated that the response to these proteins prevented infection and disease in these animals (1). HPV infection results in a variety of diseases and cancers. Low-risk or non-oncogenic HPV cause genital warts and a condition called recurrent respiratory papillomatosis (RRP), in which warts grow in the throat and/or respiratory tract. High-risk or oncogenic HPV cause various cancers and precancers. Oncogenic HPV

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types cause virtually all cervical cancers (CC), and subset of vaginal, vulvar, anal, penile and oropharyngeal cancers (2). For most of these cancers, there are no prevention strategies. Secondary prevention for CC includes CC screening with the Pap test or other methods. CC prevalence has decreased in industrialized countries over decades, but in many parts of the world, including Africa, India and South America, it is still a substantial problem. Worldwide, the ability to implement comprehensive CC screening is limited due to resource and infrastructure needs for this programme. More than half a million CC cases, and a quarter million deaths due to CC, occur each year globally (3).

HPV vaccines There are 2 prophylactic HPV vaccines available, and these vaccines have similarities and differences. The 2 vaccines are bivalent vaccine (Cervarix) and quadrivalent vaccine (Gardasil) (Table I). Both vaccines are composed of VLPs, but the vaccines have differences in how the VLPs are manufactured, which VLPs are included and the adjuvants. Gardasil prevents HPV types 16, 18, 6 and 11 infection (2 HPV types that cause CC and 2 others


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Eileen F. Dunne and Anders Koch

Table I. HPV vaccines Quadrivalent (Gardasil) Bivalent (Cervarix) Manufacturer

Merck

VLP types

6, 11, 16 and 18

16 and 18

Dose of protein

20/40/40/20 mg

20/20 mg

Producer cells Saccharomyces cerevisiae (yeast)

GlaxoSmithKline

Baculovirus-infected Trichoplusiani insect cell line

Adjuvant

Schedule (IM)

AAHS:

AS04:

225 mg amorphous

500 mg aluminum

aluminum

hydroxide

hydroxyphosphate sulphate

50 mg 3-O-desacyl-4?monophosphoryl lipid A

3 dose series

3 dose series

Abbreviations: VLP, virus-like particle; IM, intramuscular.

that prevent genital warts) and Cervarix prevents HPV types 16, 18 infection (2 HPV types that cause CC). Both vaccines have been shown in clinical trials to have high efficacy ( 95%) for prevention of cervical precancers (4,5). Gardasil has been found to have high efficacy for the prevention of genital warts, anal precancers, and vulvar/vaginal precancers (4,6). In the United States, both Cervarix and Gardasil are recommended for females and Gardasil is recommended for males. The duration of antibody response and efficacy is being followed for both vaccines, but to date there is no evidence of waning of immune response or efficacy for 610 years. The vaccines are very safe and were studied in 50,000 persons globally pre-licensure. As of June 2012, more than 46 million doses of quadrivalent vaccine have been distributed in the United States. The main adverse reactions of vaccination have included pain, swelling and redness at the injection site.

HPV vaccine implementation In 2009, WHO published a position paper on the recommendations for HPV vaccine worldwide and suggested the most appropriate target group (9- to 13-yearold girls), that HPV vaccine should not divert resources from effective CC screening programmes, and HPV vaccine should be introduced as part of a coordinated strategy for CC prevention (7). HPV vaccine has been primarily implemented in settings such as Western Europe, U.S., Canada, and Australia, but in December 2011, GAVI Alliance (Global Alliance for Vaccines and Immunisation) opened the window for funding which will make way for increased implementation worldwide (8). The revolving fund has included the HPV vaccine that will facilitate implementation in Pan American Health Organization (PAHO) countries (9).

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Areas in the circumpolar region implementing vaccine include U.S. (Alaska), Canada, Russia and Nordic countries. These countries and regions vary as far as infrastructure and support for vaccination are concerned, and whether vaccine is included in the public programme. These settings all have indigenous populations with important challenges to health care access, including rural location and language barriers. Alaska has an HPV vaccine programme similar to other parts of the United States, and has specific evaluations in place to monitor vaccine impact through collaborations with South Central Foundation and the Artic Investigations Program (AIP), Centers for Disease Control. These activities include monitoring long-term immunogenicity, evaluating HPV types in cancers from Alaska Natives and evaluating the impact of vaccination on HPV types. In Canada, HPV vaccine has been introduced and recommendations vary by province. Activities in Canada that will be unique and important to worldwide implementation include evaluations of less than 3 dose vaccine efficacy and immunogenicity.

The Nordic experience Among the 6 Nordic countries (Denmark, Sweden, Norway, Finland, Iceland and Greenland), 5 have implemented HPV vaccine. However, the primary strategies have varied across these settings. We describe the Nordic experience based on a recent publication reviewing HPV vaccine programmes in the region (10). The Nordic countries are characterized by being relatively wealthy, having mainly publicly financed health systems, with high coverage of vaccination. In addition, the Nordic countries have an effective CC screening programme, which has resulted in decreases in the incidence of CC. Despite an effective screening programme, there is an important burden of CC in these settings. Rates of CC vary significantly among the Nordic countries with Greenland having the highest incidence (25 per 100,000, age-standardized rate by World Standard Population (ASW)) (10) followed by Denmark, Norway, Iceland, Sweden and Finland (4 per 100,000 ASW) (11). Compared with other European countries, Denmark has higher rates of CC, and Finland has lower rates. Denmark was the first Nordic country to introduce HPV vaccine into the standard childhood vaccination programme, offering quadrivalent vaccine (Gardasil) since January 2009 for girls aged 12 years with a catchup programme for girls aged 1315 years. In support of this programme was a health technology report from 2007 that showed that a rapid decrease in HPV 16 and 18 infections could be expected after such a programme. In focus group interviews, parents and young people had positive attitudes towards HPV vaccination, with the cancer vaccine prevention aspect being important, whereas the risk of sexual disinhibition was not reported


HPV vaccines for circumpolar health

as being important. There was concern of inequality of health given the high cost of vaccine if not included in a free public vaccination programme. Vaccination of boys was demonstrated to double the expenses but have only a moderate effect on the incidence of CC due to herd immunity. In Denmark, there was strong public support to introduce the HPV vaccine, in particular from organizations such as the Danish Cancer Society. This resulted in the decision to also include older women born in the years 19851992 in the catch-up programme in 2012. In general, Greenland follows a similar programme to the Danish childhood vaccination programme, but the Greenland HPV vaccination programme started later. In addition to having the highest incidence of CC among the Nordic countries, Greenland has a high incidence of sexually transmitted diseases. As of 2007, vaccination with the quadrivalent vaccine (Gardasil) for both genders was planned, but a re-evaluation in 2008 changed the decision to include only girls; the programme that was initiated in 2008 was directed at girls aged 12 years with a catch-up vaccination for girls aged 1315 years. There was no substantial public debate on HPV vaccination. In Norway, the HPV vaccination programme was recommended in 2007 and introduced in 2009 with quadrivalent vaccine (Gardasil) given to girls aged 1112 years. A catch-up programme was considered but not decided upon. In contrast to Denmark and Greenland, there was some media concern about vaccine safety and even allegations of corruption against the Norwegian Cancer Registry and the expert group advising the Norwegian Public Health Institute. There were public concerns about inequality of access to vaccination, if this vaccine was not included in the public programme. The Norwegian Gynecological Society advocated in favour of the vaccine programme. In Iceland, a report in favour of public HPV vaccination was published in 2007 and bivalent vaccine (Cervarix) was first introduced in 2010 directed at girls aged 12 or 13 years, and later to girls aged 12 years only. There was

no public debate on HPV vaccination, probably as a result of the financial crisis and other competing public priorities. In Sweden, a consensus conference in 2006, and a costeffectiveness report in 2008, recommended HPV vaccination to girls aged 1012 years, as well as a catch-up programme up to age of 18 years. However, the Swedish Council on Health Technology raised concerns of vaccine safety. Despite this, in 2008 a decision was made to introduce vaccine in 2010. The first public tender amounted to 3.5 million Euros for Cervarix and 5.3 million Euros for Gardasil, but protests from gynaecologists against non-protection from genital warts and a legal appeal by Merck on the tender, resulted in a new tender in 2011 favouring Gardasil. This, in contrast, led GSK to make a legal appeal, but by November 2011 a national programme using Gardasil for girls aged 1112 years was started. Finland has the lowest rates of CC in Europe, which may have played a role in their considerations of HPV vaccination. In 2008, an advisory committee was established that by 2011 recommended an HPV vaccine programme for girls aged 11 or 12 years as well as a catch-up programme for girls aged 1315 years. The programme was endorsed in 2011 by the National Institute of Health and Welfare, but a final decision about the programme was postponed until 2014. Factors influencing the decision not to immediately introduce the vaccine, included effectiveness of CC screening, no demonstration of the ability of the vaccine to prevent cancer, lack of Finnish data on vaccine cost-effectiveness as well as burden of HPV infections, and finally, lack of funding. A number of organizations, including the National Council of Women, the Finnish Cancer Society, the Finnish Association of Midwives, and the Finnish Association of Gynecologists recommended the introduction of an HPV vaccine but to date there is no public programme. A summary of the HPV vaccine programmes in Nordic countries is included in Table II. In Denmark, vaccine

Table II. Summary of HPV vaccine programmes in the Nordic countries Start year

Target ages (years)

Administration

Vaccine

R: 2009

R: 12

Medical Home

Gardasil

Free

Planned

C: 2008

C: 1315 2028

R: 2008

R: 12

Mixed

Gardasil

Free

Partly

C: 2009

C: 1315

Norway

R: 2009

R: 12

School

Gardasil

Free

Yes

Iceland

R, C: 20112012

R: 12

School

Cervarix

Free

Yes

Sweden

R: 2011

C: 13 R: 1112

School

Gardasil

R: Free

Yes

Finland

Not decided

Denmark Greenland

Cost through public programme

Vaccine register

R, routine; C, catch up. Source: Reference 10. Citation: Int J Circumpolar Health 2013, 72: 21070 - http://dx.doi.org/10.3402/ijch.v72i0.21070

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coverage rates for girls born between 1993 and 1998 were 8690% for the first dose of vaccine, similar to measles vaccine coverage rates given at the same age; 7683% had completed all 3 doses of the vaccine (12). In Norway, vaccination for girls born in 1998 was 79% for vaccine initiation and 70% for all 3 doses (13). For Sweden, vaccine coverage of girls aged 1317 years until 2011 was 30% (while not in the public programme) (14); a webbased questionnaire in 2012 showed 80100% initiation of vaccine in more than 80% of schools with inclusion in the public vaccination programme (15). HPV vaccine coverage rates in other European countries are generally lower than Nordic countries: for school-based vaccination in the United Kingdom and Scotland, coverage rates were 76% (16) and 90% (17) for 3 doses of vaccine; for Slovenia 49% (18) and the Netherlands 50% (19). Vaccine prices varied substantially between the countries and from first to second tenders in each country. Greenland and Sweden obtained vaccines at lower cost than Denmark, as Denmark was the first country to introduce the vaccine. In summary, there are numerous lessons learned from HPV vaccine considerations in Nordic countries. In spite of similar culture and health systems, there are marked differences in HPV vaccination strategies, priorities, debate and concerns. Vaccine introduction was generally supported initially in countries with higher CC rates; first introduction in the high-incidence countries of Denmark and Greenland, and still awaiting introduction in the lowincidence country of Finland. Both the quadrivalent vaccine (Gardasil) and the bivalent vaccine (Cervarix) have been used, although use of the quadrivalent vaccine is more common. There are varying vaccine coverage rates from satisfactory in Denmark to less satisfactory in Norway. Purchasing prices have varied substantially between countries and year of purchase, with later tenders being markedly cheaper than first tenders. There were differences in public debate over vaccination, with a lively debate in Denmark and Norway and no debate in Greenland and Iceland. Public voices ranged from request for vaccination in Denmark to concern about vaccine safety in Norway. Health professionals were active in the debate, most in favour, although there was some concern by health professionals in Norway. There are many interested parties including the Danish Cancer Society lobbying for HPV vaccine programmes and mass media; in Denmark HPV vaccination became a political issue in the Parliament. Vaccine manufacturers in particular have been highly active in the debate in these settings, lobbying, making public complaints, and filing lawsuits. Reasons for public support for HPV vaccination in the Nordic countries, include protection against cancer and reduction in social inequality in health with a public programme, potential sexual disinhibition from vaccination has been of little concern. Because of the varied

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approaches and issues, the experience of Nordic countries may be useful for other jurisdictions considering vaccine implementation.

Conflict of interest and funding The authors report no conflict of interest.

References 1. Breitburd F, Kirnbauer R, Hubbert NL, Nonnenmacher B, Trin-Dinh-Desmarquet C, Orth G, et al. Immunization with virus like particles from cottontail rabbit papillomavirus (CRPV) can protect against experimental CRPV infection. J Virol. 1995;69:395963. 2. CDC. Human papillomavirus associated cancers*United States 20042008. MMWR Morb Mortal Wkly Rep. 2012;61:25861. 3. GLOBACAN 2008 Estimates. [cited 2012 Oct 29]. Available from: http://www.gavialliance.org/support/apply/. 4. The FUTURE II Study Group. Quadrivalent vaccine against human papillomavirus to prevent high-grade cervical lesions. N Engl J Med. 2007;356:191527. 5. Paavonen J, Naud P, Salmeron J, Wheeler CM, Chow SN, Apter D, et al. Efficacy of human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine against cervical infection and precancer caused by oncogenic HPV types (PATRICIA): final analysis of a double-blind, randomised study in young women. Lancet. 2009;374:30114. 6. Giuliano AR, Palefsky JM, Goldstone S, Moreira ED Jr, Penny ME, Aranda C, et al. Efficacy of quadrivalent HPV vaccine against HPV infection and disease in males. N Engl J Med. 2011;364:40111. 7. WHO HPV vaccine recommendations. [cited 2012 Dec 10]. Available from: http://www.who.int/wer/2009/wer8415.pdf. 8. GAVI funding for HPV vaccine. [cited 2012 Oct 29]. Available from: http://www.gavialliance.org/support/apply/. 9. CDC. Progress toward implementation of HPV vaccination* the Americas*20062010. MMWR Morb Mortal Wkly Rep. 2011;60:13824. 10. Sander BB, Rebolj M, Valentiner-Branth P, Lynge E. Introduction of human papillomavirus vaccination in Nordic countries. Vaccine. 2012;30:142533. 11. Engholm G, Ferlay J, Christensen N, Gjerstorff ML, ˚ , et al. NORDCAN: cancer inciJohannesen TB, Klint A dence, mortality, prevalence and survival in the Nordic countries, Version 4.0. Association of the Nordic Cancer Registries, Danish Cancer Society; 2011. [cited 2011 Aug 26]. Available from: http://www.ancr.nu. 12. Statens Serum Institut. HPV vaccination, coverage 2011. EPINEWS 2012; 22: 30 May 2012. [cited 2012 Aug 12]. Available from: http://www.ssi.dk/English/News/EPI-NEWS/2012/No% 2022%20-%202012.aspx. ˚ rsrapport for HPV13. Norwegian Institute of Public Health. A vaksine I barnevaksinasjonsprogrammet 2011 [in Norwegian: Yearly report for HPV vaccination in the childhood vaccination program]. 2012:14. [cited 2012 Aug 12]. Available from: http://www.fhi.no/dokumenter/7be0dcf494.pdf. ¨ vervakning af HPV-vaccination I 14. Smittskyddsinstitutet. O Sverige [in Swedish: Surveillance of HPV infection in Greenland]. 2012:134. [cited 2012 Aug 12]. Available from: http:// www.smittskyddsinstitutet.se/upload/Publikationer/overvakningav-HPV-vaccination-i-Sverige-2012-15-9.pdf. 15. Smittskyddsinstitutet. Resultat av en webbaserad enka¨tunderso¨kning avseende HPV-vaccination inom skolha¨lsova˚rden av flickor fo¨dda 1999 och 2000 fram till 2012-05-23 [In Swedish: Results of a web based enquiry on HPV vaccination through the


HPV vaccines for circumpolar health

school health service to girls born 1999 and 2000 until May 23, 2012]. 2012:14. [cited 2012 Aug 12]. Available from: http://www. smittskyddsinstitutet.se/upload/PDF-filer/sammanstallning_ hpvenkat_smi.pdf. 16. The Information Services Division. Provisional HPV immunisation. Uptake statistics year 3 of the HPV immunisation program (2010/11). [cited 2011 Sep 2]. Available from: http://www.isdscotland.scot.nhs.uk/Health-Topics/Child-Health/ Publications/2011-03-24/110324-HPV-Immunsation-Report.pdf? 16874331236. 17. Department of Health. Annual HPV vaccine coverage in England in 2009/2010. [cited 2011 Sep 2]. Available from: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/ documents/digitalasset/dh_123826.pdf. 18. Institut za varovanje zdravja Republike Slovenije. Precepljenost (delez cepljenih) deklic 6. razredov OS s 3 odmerki cepiva proti HPV, solsko leto 2009/20010 [Immunization (vaccination coverage) of girls in the 6th grade of elementary school with

three doses of the vaccine against HPV, school year 2009/2010]. [cited 2011 Sep 8]. Available from: http://www.ivz.si/Mp.aspx? ni201&pi5&5 id1399&5PageIndex0&5groupId322&5 newsCategory&5 actionShowNewsFull&pl201-5.0. 19. Rondy M, van Lier A, van de Kassteele J, Rust L, de Melker H. Determinants for HPV vaccine uptake in the Netherlands: a multilevel study. Vaccine. 2010;28:20705. *Eileen F. Dunne 1600 Clifton Rd MS E-02 Atlanta, GA 30333 USA Tel: 1-404-639-6184 Fax: 1-404-639-8610 Email: [email protected]


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Native voices: native peoples’ concepts of health and illness Donald A.B. Lindberg* National Library of Medicine, Bethesda, Maryland, USA

he National Library of Medicine (1), which I have the privilege to direct, is the world’s largest medical library. Our programs and services range from consumer health information sites to collecting and disseminating medical literature to genetic data (2) in support of the Human Genome Project (3). Our rich collections are the largest in the world and range from 11th century manuscripts to contemporary electronic journals from around the globe. The Library also develops exhibitions (4) and educational resources (5) that enhance awareness of and appreciation for the NLM collections. These exhibitions and resources engage diverse audiences and explore a variety of topics in the history of medicine. Exhibitions are featured both in the NLM’s Rotunda Gallery, on the NIH (6) campus in Bethesda, Maryland, and online. To give them the broadest possible exposure, we produce traveling exhibitions as well, which are available free of charge to the public. The NLM recently opened an interactive exhibition examining concepts of health and medicine among contemporary American Indians, Alaska Natives, and Native Hawaiians. Entitled, Native Voices: Native Peoples’ Concepts of Health and Illness (7), it explores the connection between wellness, illness and cultural life through a combination of artwork, objects, interactive media and interviews with Native people. Let me share with you what you will find if you visit, as I hope you will, Native Voices. If you wander into this exhibition, you will hear Native Americans speak about their own ideas of health and illness, how they arrived at these perspectives, and how death fits in to the picture, too. They will speak of traditional healing ways, modern treatments, and their ideas about loyalty to country and appreciation of military service. The National Library of Medicine chose to present this exhibition because of our growing admiration for many of the ideas and practices of American Indians, Native Alaskans, and Native Hawaiians. These people do have different mental models or attitudes, if you like about life. But they also share important beliefs.

T

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First, Native peoples seem to us to share a common view that each person has a responsibility for his or her proper behavior and health. This includes such matters as diet, exercise, traditional or Western medical treatment, and hospice care. Second, you will gain a sense of how these Native people place the tribe the group, the village at the centre of their beliefs about health and happiness. You’ll learn about the rebirth of voyaging and the re-creation of historic canoes of Hawaii how these are rebuilding the people’s pride in their group and its sea-going history. You will see Choctaw boys and girls taking charge of their own health, through the traditional sport of stickball. Third, there is a common high regard for nature - the climate, the plants, the animals, the land itself. It’s a complex and fascinating point of view that blends physical reality with spirituality. Fourth, when you listen to the interviews, you will surely hear a reverence for traditions, for tribal Elders, and for a Supreme Being. Fifth, the Native groups all share a history that is lamentably full of rough, unfair treatment, as our modern American and Western European industrial civilizations enveloped Native lands, abolishing ancient sources of pride. Our exhibition timeline shows the history of groups. Interviews of individuals suggest that loss of pride and purpose can be serious obstacles to healthy living and even to recovery from illness. Our exhibition is also about young Native people today and how they incorporate all of these experiences in their own ways, to help make their lives happy and healthy. A common thread throughout the exhibition is the art of Native people. The art objects represent the ideas of the people often magnificently. This exhibition honours the Native tradition of oral history and establishes a unique collection of information. We hope that you and all visitors will find Native Voices educational and inspirational, and we also hope that Native people will view it with pride.



References 1. U.S. National Library of Medicine. [cited 2013 Jun 26]. http:// www.nlm.nih.gov 2. National Center for Biotechnology Information. [cited 2013 Jun 26]. http://www.ncbi.nlm.nih.gov/ 3. National Human Genome Research Institute. [cited 2013 Jun 26]. http://www.genome.gov/10001772 4. U.S. National Library of Medicine Exhibition Program. [cited 2013 Jun 26]. http://www.nlm.nih.gov/hmd/about/exhibition/ index.html

5. U.S. National Library of Medicine Exhibition Program Education Services. [cited 2013 Jun 26]. http://www.nlm.nih.gov/hmd/ about/exhibition/education-home.html 6. National Institutes of Health. [cited 2013 Jun 26]. http://www. nih.gov 7. National Institutes of Health, Native Voices. [cited 2013 Jun 26]. http://www.nlm.nih.gov/nativevoices/

*Donald A.B. Lindberg Email: [email protected]


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An Alaska Native leader’s views on health research H. Sally Smith* Alaska Native Tribal Health Consortium, Anchorage, AK, USA

hen I was a little girl, I remember my mother saying ‘‘those outsiders are here again to ask us foolish questions and take our spit or blood.’’ I am pleased to speak to you today about health research from the perspective of an Alaska Native Yup’ik woman, a tribally enrolled member and a tribally elected leader. It is undeniable that health research is necessary to improve health care and health outcomes for Alaska Native people. Alaska Native people have had a history of being ‘‘researched.’’ We did not participate in developing the research conducted on us. Once the researchers went away, that was the last that we saw of them, or heard anything about them. We were trusting and agreeable to these outsiders, but over time we came to mistrust these strangers who came to ask us questions, and to take our spit or take our blood. I am here today to underscore that we have turned our views of health research from a position of mistrust, to the current position of fostering research, especially community-based participatory research. In order to understand why Alaska Native health research is so important, you must first hear a bit of our history. It used to be that most Alaska Native people lived out in the villages. As time passed, many of us moved to bigger hub villages. Today, Anchorage is the largest Alaska Native village in the state (1). Living in the villages was not easy. We followed a subsistence way of life and many of us still do today. But life was simpler; it seemed, in other ways. Many decisions were made for us; the federal government ‘‘did for us.’’ They ‘‘took care of us’’ and we were accustomed to ‘‘those guys’’ coming to our villages to line us up for an x-ray, give us immunizations and collect data. That was just the way things were, we did not have input into their ways of doing things, even if we disagreed with them. After the 1950s policies of tribal termination and the 1960s era of civil rights, the US Congress expanded recognition and application of Tribal self-government,

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much like it did in 1934 through the Indian Reorganization Act (2). In the 1970s, changes in the way Alaska Native people interacted with the federal government happened practically overnight. With the passage of the Alaska Native Claims Settlement Act in 1971 (3), regions were formed and villages found themselves grouped geographically together under a corporate structure. Today, there are 13 regional corporations. These for-profit and not-for-profit corporations formed the natural boundaries for regional health organizations and consortia. Through the passage of the Indian Self-Determination and Education Assistance Act in 1975 (4), a very significant law delegating authority to Indian tribes to provide their own services was created by the federal trust responsibility. This Act is referred to as Public Law (PL) 93-638. The Act allows Tribes to assume administrative responsibility for federally funded programs designed for their benefit, primarily services which are administered by the Bureau of Indian Affairs and by the Indian Health Service. This means that Tribes can negotiate contracts and compacts directly with the federal government to run their own programs and deliver their own services, rather than the federal government ‘‘doing’’ it for them. The Act has been amended many times, allowing for greater selfdetermination to Tribes. In 1988, the Act was amended to make it harder for the federal government to deny PL 93-638 contract proposals that Tribes put forward. The 1988 amendment also created the Tribal Self-Governance Demonstration project, which was an experiment in compacting a total of 20 Tribes nationwide. Compacting is a formal negotiation process that occurs between Tribes and Tribal organizations and the US Government. It is a government-to-government relationship. In 1994, amendments to the Act expanded Tribal Self-Governance. This authorized the opportunity to compact up to 20 new Tribes each year, if certain criteria were met.

Presentation at the 15th International Congress on Circumpolar Health, Fairbanks, Alaska.

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The 1994 amendments allowed the Indian Health Service (IHS) to compact its programs for the first time. There were only 2 slots left in this demonstration period. Rather than compete across the state for these 2 remaining slots, the Alaska Tribal Caucus came together and formulated a different approach; they came together very much like a family. When we talk about the Alaska Tribal Caucus, we talk about all 229 Tribes in Alaska. Imagine in your mind 229 people seated in a room discussing issues and coming to consensus. The 12 Tribal health organizations/consortia met and by consensus, agreed to negotiate a single compact for all of the Tribes in Alaska. This is known as the ‘‘Alaska Tribal Health Compact (ATHC)’’ (5). The ATHC functions as an umbrella for the Tribes and Tribal health organizations (THOs). These organizations work together while maintaining their own autonomy to participate in health compacting, or contracting. Each Tribe or Tribal organization retains the authority to negotiate their own funding agreement with the federal government. Every spring, all of the Tribes come together and conduct pre-negotiations. We come together and the first thing we have is a Tribal Caucus. This is where we outline the issues of the year, those issues that are important to our communities. An example of an important issue would be ‘‘water and sanitation.’’ How many of our villages still do not have running water? We talk about how many of our villages are lacking in health related areas. As tribes, we discuss together until we reach agreement or consensus on what issues are most important to our people. It is important to understand the miracle that is the ATHC. It is the only compact of its type in the United States. It is important to realize that the Alaska Tribal Health System is a structure where all 229 Tribes work together. One complements the other, meaning the Alaska Tribal Health Compact and the Alaska Tribal Health System work together. They intertwine, in a complex pattern, reminding me of the baskets my mother used to make. The ATHC forges a strong pillar of trust between all 229 Tribes. It is that trust that surrounds the process Tribes and Tribal organizations have put into place to address health related issues. Some of these health related issues focus on research. This research is now conducted with us. We have input and jurisdiction over what type of research is conducted and how the resulting information is shared.

Changes that have taken place: how health research is reviewed, conducted and disseminated in Alaska Native communities Health research review by Tribal Health Organizations (THO) in Alaska has gone from little to no tribal oversight to organization review structures that involve tribal leadership. PL 93-638 provided Tribes and THOs

the ability and flexibility to design our own health programs. In 1997, the Alaska Native Tribal Health Consortium (ANTHC) was created by a specific piece of legislation, PL-105-83, section 325 was introduced by Alaska Senator Ted Stevens to provide statewide health services to Alaska Native people (5,6). Assumption of ownership and management of the Alaska Native Medical Centre included the Institutional Review Board (IRB), which had been under the Indian Health Service IRB. The Alaska Area Institutional Board (AAIRB) was the first formal structure put into place to work directly with research review that was conducted in Alaska Native communities.

Alaska area institutional review board Many of you are familiar with institutional review boards and references to 45 CFR 46 in the Code of Federal Regulations (7). Title 45 is Public Welfare, Department of Health and Human Services, National Institutes of Health, Office for Protection from Research Risks and Part 46 is Protection of Human Subjects effective August 19, 1991. Hand-in-hand with that is the Belmont Report 1979 Ethical Principles and Guidelines of Respect, Beneficence, and Justice. These guide the Alaska Area Institutional Review Board. The AAIRB meets monthly. Its members are dedicated volunteers. The AAIRB review process asks: ‘‘Is the proposal research?’’ If the answer is ‘‘yes,’’ then the next question is, ‘‘Is participation in the project of minimal risk?’’ If that answer is yes, then, they ask, ‘‘does this project fit’’ the ‘‘Exempt Research’’ or the ‘‘Expedited Research’’ category per 45 CFR 46? If the answer is ‘‘no,’’ then the project goes through a full review by the AAIRB. If the answer is ‘‘no’’ on the question of ‘‘is it research?’’ no IRB review is necessary. Examples of nonresearch proposals could include: public health, program evaluation, or quality improvement. All research that occurs at the Alaska Native Medical Centre is reviewed by the AAIRB. We needed to build a framework that extended the work of the AAIRB and brought the research review process to the Tribal level to include community leaders in the decision-making process of what is researched in their communities and how that research is conducted and shared. Alaska Native Tribal Health Consortium research review The ANTHC developed a process for research review, and like many processes, it too has changed over time. The process includes AAIRB review and approval, previously discussed. The researcher then submits their proposal to the ANTHC Research Abstracts, Manuscripts and Proposals (RAMP) Review Committee. The RAMP committee is comprised of volunteer staff


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representing the Alaska Native Medical Centre (ANMC) and the ANTHC. They review the submissions for technical, clinical and cultural appropriateness. Their recommendations for approval of proposals and manuscripts are advisory in nature. The HRRC is comprised of appointees made by the ANTHC Board President/Chairman to review health-related proposals, publications, and presentations as a part of the Tribal review process. The HRRC meets at least quarterly. The ANTHC HRRC reviews and approves proposals that have received a ‘‘minimal risk’’ determination by the AAIRB. These proposals, along with all manuscripts are approved by the HRRC on behalf of the ANTHC Board of Directors. If the risks are not ‘‘minimal’’ the process goes one step further. The proposal goes to the ANTHC Board of Directors for review and approval.

Research review in tribal health organizations As the ANTHC reviews research that involves the Alaska Native Medical Centre, the THOs are also involved with research review and approval in their regions. Each THO has its own procedure for this process. I have elected to use the Bristol Bay Area Health Corporation (BBAHC) as the example for individual tribal health organization research review and approval. Concept proposals When a researcher is contemplating a project, they need to be going through a checklist. They need to ask themselves; ‘‘Is this project something that the tribal council is interested in?’’ Tribal council, meaning the Native Village of Ekuk, the Native Village of New Stuyahok, the Native Village of Kake, meeting with the local tribal health board to determine support is usually accomplished even before the protocol has been written. We call this the ‘‘twinkle in the eye’’ concept ‘‘Does this project fit in with the health priorities of elected tribal leaders?’’ Once written, the protocol is sent to the Alaska Area IRB. This process of approval can take over 6 months if the project does not take 45 CFR 46 requirements and the principles of the Belmont Report into account. This approval is really important. Approval from the tribal council and the tribal health organizations is also obtained. I serve on several health boards, I understand the research review process. It is important to present your study to the tribal council in a meaningful and relevant manner. These tribally elected leaders of the villages are the moms and dads you see at the post office. They are everyday people working to make a difference. The next step of approval entails consent with the participant, who is going to be a part of the study. You must have their consent for the study and consent for storage of any specimens in the specimen bank (if the research includes the collection of specimens). If specimens are collected, a

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participant may elect to have their specimen disposed of when the study is complete, rather than stored. An ethics committee or another committee may review the research proposal at the THO level. It would minimally require the following elements for research protocols: All research must comply with 45 CFR 46 regarding research on human subjects. The AAIRB reviews and approves all human subject research protocols submitted prior to regional review. (Some regions, such as Southcentral Foundation require a concept review, prior to submitting a full proposal.) The research request must be submitted and approved by the BBAHC Ethics Committee, the medical staff and the regional board of directors. The Ethics Committee evaluates specifics of the informed consent.

Standards of regional approved protocols Informed consent must be obtained from patients asked to participate in a study project. All patients/clients asked to participate in research are given a description of the expected benefits and the expected risks of participation. They are given a full explanation of the procedure to be followed, especially those that are experimental in nature. They are told that they may refuse to participate and that their refusal will not compromise their access to services. Participants are told that they may elect to end their participation in the study at any time without compromising their access to services. Participants are given the name of the individual who provided the study information and obtained informed consent from them. Regional approval of proposals for community research and investigational and clinical trials Proposals for all research including investigational and clinical trial projects submitted to the regional health corporation are directed to the president/CEO and the Ethics Committee Chairperson. The Ethics Committee analyzes risk versus anticipated benefits and the importance of the research knowledge to be gained by the proposal. The Ethics Committee reviews the qualifications of the investigators. We believe this review is very important. We do not allow everyone to come into our communities and conduct research. We want research, but we want it done right, and we want it done well. The Clinical Director reviews the proposal with the medical staff and presents their recommendations to the chairperson of the Ethics Committee. The proposal is forwarded to the Board of Directors for final review and approval. We have 34 villages in BBAHC that meet once a year and we have an 11 member executive committee that meets monthly. Continuing review of approved projects There are continuing review and reporting requirements determined by the regional Ethics Committee, the Alaska Area IRB, the regulatory requirements of the Food and



Drug Administration (FDA), and the Office for Human Research Protections 45 CFR 46 regulations. Some investigational and clinical trials may require reporting on a more frequent basis; the level of risk of participation in the research project determines this. The regional board retains the right to request the researcher/investigator to report at the conclusion of the project.

Dissemination Communicating your results back to the participants is the key to a successful study. Usually a letter with a summary of the findings is sent back to the participants. There are other ways of communicating these results back that include posters, newsletters, etc. We want to hear back from the researchers about what was learned. Bio-banking of specimens Some research involves the collection of biological specimens. All specimens taken for any study remain the property of the participant. These specimens are stored at the Alaska Area Specimen Bank (AASB). The Alaska Area Specimen Bank (AASB) is a Tribalfederal government partnership formed to maintain and manage a resource for health research. This ensures that stored biological specimens collected as part of research studies are used in accordance with the conditions of informed consent, the health priorities of Alaska Native people, and the principles of good scientific methods. This bank of biological specimens has been collected over the years by research studies, public health investigations, and clinical testing. Samples are collected from study participants who agreed to have specimens stored for future use. A participant can ask to have their specimen removed at any time. Specimens can only be used in research that has been approved by THOs and the AAIRB. The Specimen Bank Working Group comprised of members from the ANTHC and the Centre for Disease Control Arctic Investigations Program (8) provides oversight of the AASB. The specimen bank is used to conduct research and remains a carefully managed resource to improve the health of Alaska Native people. The AASB is housed at the CDC-AIP on the ANMC campus, in Anchorage, Alaska. The Indian Self-Determination and Education Act (PL 93-638) provided Alaska Native people the authority to assume management of their own delivery of health care and the flexibility to expand to other programs such as health research conducted in Alaska Native communities. Over time, research, data ownership, informed consent, and individual specimen’s ownership have been determined by the Alaska Native people. That is an example of how partnerships by the right mix of organizations, federal and tribal, produce; an operational system that engages the Alaska Native community in the process of managing a specimen bank. The policies and procedures were developed in partnership with the Alaska Tribal

Health System and the federal government. This resulted in the formation of an advisory working group with Alaska Native THO representation providing oversight of the specimen bank and establishing a forum for ongoing discussion and resolution of concerns and issues related to use of banked specimens. This Tribal-federal partnership established for the co-management of the specimen bank fits well with the ATHS and is consistent with Tribal sovereignty and self-determination in areas of human health research. This partnership created a management structure that includes both the cultural expertise of Tribal leaders with the scientific and public health expertise of the CDC-AIP. Adoption of the AASB protocols would have been more difficult if it were not for the integration of the ATHS where statewide decisions are made through consensus by all 229 tribes. Research involving Alaska Native people is becoming more acceptable as community-based participatory research becomes the norm. We have a system replete with protocols, which are respected by our research partners and partner organizations. Formation of the Specimen Bank Working Group consisting of Alaska Native Tribal health representatives and representatives of a US Federal program (CDC-AIP) to develop policies and procedures was critical. In Alaska, we truly operate as Tribal-federal partners to maintain and manage a valuable resource for health research.

Current and future research The ANTHC Health Research Review Committee was instrumental in forming partnerships with CDC-AIP, University of Alaska, and others to host 3 research conferences focusing on Alaska Native health research. The purpose of these conferences was to provide a forum to highlight the Alaska Native health research being conducted in our communities with our people. These conferences provided networking and discussion between Alaska Native community members, health care providers, and health researchers. The conferences focused on the capacity for health research in communities, bridging the divide between traditional wisdom and western science; blending Elder wisdom with Youth technology, to provide direction and focus in community research. As a tribal leader, I am thankful that research projects continue in our tribal communities in our regions and at the statewide level. We work tirelessly to ensure that the current research carried out reflects the needs and the priorities of communities.

Conclusion The community needs to be involved with the research. The community must have the opportunity to review the research (study) and receive the results. Any biological samples must be handled with respect and in accordance


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with the wishes of the individuals from the communities; samples remain the property of the individual. We are coming to understand that to be healthy and remain healthy we need research, and when possible, we need community-based participatory health research that includes researchers from our communities (9). By our people and for our people is what we must encourage (10). We need to foster and nurture research based on the foundation of science and traditional knowledge that together promotes new learning and understanding. We feel we have a choice in whether to participate in research, or not. We want to know the results of the research conducted with us. We are more than individual Alaska Native families. We are a strong and resilient people with common core values of trust, sharing, and respect for elders. These are values shared by people all over the world. These values are taught by example, embraced by one and all, and become incorporated into our daily lives as naturally as we draw a breath. These values are part of what will continue to sustain good health research. We may use different words and approaches to explain research to our communities. Many Alaska Native people are natural storytellers. We welcome those of you who want to work with us on our future story. Thank you for embracing my words. Thank you for the opportunity to share with you.

References 1. Indian Health Service Alaska Area. (2010). Alaska Native 2010 Official IHS Active User Population Report (B), Version 43 Report Date: 12/2/2010. [cited 2013 Jun 26]. Retrieved from http://www.ihs.gov/alaska/documents/pop_reports/FY2010IH SOfficialAIANUserPop.pdf

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2. Warne D. Policy challenges in American Indian/Alaska Native health professions education. J Interprof Care. 2007;21:119. 3. University of Alaska Fairbanks. (n.d.). Federal Indian Law for Alaska Tribes: Alaska Native Claims Settlement Act (ANCSA) 1971. [cited 2013 Jun 26]. Available from: http://tm112. community.uaf.edu/unit-3/alaska-native-claims-settlement-actancsa-1971/ 4. US Department of the Interior (DOI) Bureau of Indian Affairs (BIA) & US Department of Health & Human Services (DHHS) Indian Health Service (IHS). 1996. Public Law 93638. Indian Self-Determination and Education Assistance Act, as Amended. [cited 2013 Jun 26]. Available from: http://www. bia.gov/cs/groups/mywcsp/documents/collection/idc017334.pdf 5. Alaska Tribal Health System. 2008. About the Alaska Tribal Health System. [cited 2013 Jun 26]. Available from: https:// www.alaskatribalhealth.org/about/aboutATHS/ 6. Alaska Native Tribal Health Consortium. 2012. About the Alaska Native Tribal Health Consortium. [cited 2013 Jun 26]. Available from: http://anthctoday.org/about/index.html 7. US Department of Health & Human Services (DHHS) Office of Human Research Protections (OHRP). 2010. Code of Federal Regulations Title 45 Public Welfare Department of Health and Human Services Part 46 Protection of Human Subjects. [cited 2013 Jun 26]. Available from: http://www.hhs. gov/ohrp/humansubjects/guidance/45cfr46.html 8. Centers for Disease Control and Prevention (CDC) Arctic Investigations Program (AIP). 2011. Division of Preparedness and Emerging Infections (DPEI): about Arctic investigations program. [cited 2013 Jun 26]. Available from: http://www.cdc. gov/ncezid/dpei/aip/about.html 9. Cochran PAL, Marshall CA, Garcia-Downing C, Kendall E, Cook D, McCubbin L, et al. Indigenous ways of knowing: implications for participatory research and community. Am J Public Health. 2008;98:227. 10. Smith HS, Bjerregaard P, Chan HM, Corriveau A, Ebbesson SOE, Etzel RA, et al. Research with Arctic peoples: unique research opportunities in heart, lung, blood and sleep disorders. Int J Circumpolar Health. 2006;65:7990. *H. Sally Smith Email: [email protected]



Northern leaders perspective on Arctic development Patricia A.L. Cochran* Executive Director, Alaska Native Science Commission, Anchorage, AK, USA

s former head of an organization that represents Inuit around the circumpolar world, in this article I will focus on the experience of Inuit in my home in Alaska. This is partly because I know that experience best, and can discuss it with the knowledge that comes from personal experience. It is also because the Inuit in Alaska have the longest history of living with oil and gas development, compared to other parts of the Inuit world.

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Problem identification More than 30 years ago, a man named Eben Hopson appeared before the Mackenzie Valley pipeline inquiry in Canada. This inquiry was trying to figure out whether a pipeline that would begin the exploitation of large gas reserves in the Canadian Arctic should be allowed. Eben Hopson was an extraordinary man, an Inupiat who helped lead the push for land claims in Alaska, and he was instrumental in forming the Inuit Circumpolar Council. Hopson gave this inquiry a full account of his views of oil and gas development. He was not anti-development. As mayor of the North Slope Borough in Alaska, he used revenues from development to help build roads and houses, to improve the lives of the Inupiat. But he had also seen the downside of development, and was most concerned about how the sudden influx of oil and gas money distorted local economies, that it in turn distorted local cultures, local societies, and local politics. ‘‘I am very concerned,’’ Hopson told the Inquiry, ‘‘about the long-term economic impact of oil and gas development upon our Arctic community. We are riding the crest of a high economic wave, and I fear about where it will deposit us, and how hard we will land.’’

How hard we will land Now, more than 30 years later, we are still riding that wave, still wondering where, and how hard, we will land. In those 30 years, we have gotten some ideas about what effects we can expect, and what others might learn from our experiences.

We have seen effects on the animals on which we have traditionally relied for subsistence. Our observations, backed up by scientific studies, have concluded that noise from underwater drilling and seismic work has driven away Bowhead whales. This has driven our hunters further offshore, following the whales into increasingly dangerous waters. We are intensely afraid that there will be a major oil spill in our traditional area. We saw what happened as the result of the Exxon Valdez spill and the blowout in the Gulf. If the coastal resources on which we rely are polluted, then the bottom drops out of our culture. We need that link to the land, to our history, to our traditions. In many cases we still need the food, as even with the extra money coming into our regions from oil and gas, food prices are very high. And getting to our traditional foods is more and more expensive as gas prices increase one of the reasons some hunters are going back to using traditional dog teams. Perhaps the lesson other regions can draw from our experience is to be sure that oil and gas technologies have been thoroughly tested before they are used in your area. Is there truly a technology that can clean a spill in ice-infested waters; can a reduced exploration season maintain a balance in subsistence resources? Another important lesson is that critical habitat for subsistence food resources should be protected in advance of oil and gas development. Knowledge is key to dealing with oil and gas development. What we have learned in our region is that the commitment to knowledge, to learning about oil and gas effects, must be continuous.

Background ‘‘Landing’’ from our current economic wave may be one of the most difficult impacts of oil and as development on our Inupiat communities. In the 40-plus years since the discovery of the Prudhoe Bay field, our communities, our society and culture have been transformed by the addition of cash from those developments. But when the wells eventually run dry, those communities who have maintained traditional ways of life and built up enough


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• One quarter of all untapped reserves are north of the Arctic Circle • Impacts on many communities • Need to be prepared – especially politically • Need to be involved on a decision-making level

• Do not abandon your previous lives • Maintain traditional ways of life • Extract local benefits while oil is still flowing

Fig. 1. Lessons we have Learned.

local financial capital are likely to have a softer landing when the wells run dry (Figure 1). As we look to the future of oil and gas exploration in and near Inuit homelands, where the federal government estimates there are more than 26 billion barrels of recoverable oil and 130 trillion cubic feet of natural gas in the Arctic Ocean’s outer continent shelf reserves in the Beaufort and Chukchi, it is unquestionable that the Arctic as a whole will become ever more important in the coming decades. From the shores of Chukotka, ever deeper into the Beaufort Sea, through Canada’s Arctic islands to Greenland, the rigs are coming. This means that those pockets of the circumpolar world that have so far mostly escaped the inroads of industrial development will shrink, and may ultimately disappear. The global thirst for oil and gas is such that it is not a question of if exploration will come, but when. We need to be ready, more ready than we were in Alaska. One important way in which we can be ready is to be politically ready. We are already experiencing more political pressure to develop oil and mineral resources, sometimes downplaying the environmental and social costs to our communities and ways of life. Wherever development occurs in the Inuit world, it cannot be a process that goes on above the heads of local people. Decisions made by remote control in southern centres, no matter how well intentioned, cannot understand the reality of the lives of Inuit living in small Arctic communities. The Inuit must be involved, not just on a

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Fig. 2. Future Developments.

consultative level, but also on a decision-making level. How many times have we heard this and how do we actually achieve it? (Figure 2).

Conclusion As residents of the Arctic, the First Alaskans, we recognize the importance of oil, gas, mineral, and other development activities and the significant role these discoveries have made in the lives of our peoples and communities. We also recognize the loud call of our mother earth to live in harmony to remember that which has sustained us for centuries. We must balance the needs of humans with the needs of the planet we live upon. May we find that balance for our generations to come.

Suggested readings 1. Alaska Native Knowledge Network. Available from: http:// www.ankn.uaf.edu/ 2. Impact of Climate Change on Alaska Native Communities. Available from: http://www.nativescience.org/assets/Documents/ PDF%20Documents/Impact%20of%20Climate%20Change%20 on%20Alaska%20Native%20Communities.pdf 3. Alaska Native Science Commission. [cited 2013 Jun 26]. Available from: http://www.nativescience.org/index.htm *Patricia A.L. Cochran Email: [email protected]


CHAPTER 3. Behavioral Health

BEHAVIORAL HEALTH æ

Evolution of behavioral health issues in the circumpolar north in the 45 years of the ICCH * Introduction Vanessa Hiratsuka

ehavioral health in the circumpolar context refers to an interdisciplinary field concerned with the development, integration and application of social and biomedical sciences and approaches to understand, maintain and improve the health and wellness of individuals and the communities in which circumpolar residents live. The term behavioral health encompasses mental health, substance abuse and behavioral medicine as well as the underlying social causes of healthy and unhealthy behaviors. In 1967, a symposium on Circumpolar Health Related Problems was convened in Fairbanks in which 39 papers were presented (1). At that inaugural meeting of the circumpolar research community, the papers presented included descriptions of the people and places that comprise the circumpolar north, tuberculosis, clothing and adaptation to the cold, and circumpolar mental health (2). Forty-five years later, the papers presented in the Behavioral Health sessions at the 15th International Congress on Circumpolar Health (ICCH15) held in Fairbanks, Alaska, reflect the multiple facets of the behavioral health. Over the course of the 5-day Scientific Program, 6 behavioral health breakout sessions and a poster session occurred during the ICCH15. The presentations at the ICCH15 explored: (a) tobacco use and prevention; (b) alcohol use, policy and prevention; (c) mental wellness; (d) domestic violence; (e) suicide risk factors; and (f) suicide prevention. The proceedings of the ICCH15 include 23 papers on the topic of behavioral health. As noted by Pamela Orr in the ICCH14 proceedings, the quantity and content of papers continue to grow with each successive meeting of the ICCH (3). The papers included in the behavioral health section of the ICCH 15 proceedings comprise clinical and epidemiological descriptions of behavioral health conditions and risk factors, the impact of traumatic experiences, behavioral health workforce development, programs developed to address behavioral health issues within the circumpolar north, and the effects of geopolitics on the physical, mental, spiritual and emotional health of individuals and communities. These topics were explored from a variety

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of perspectives: within distinct small, rural communities of the North, on a national perspective, within indigenous peoples, and as case studies. Looking at the different perspectives within a subtopic of behavioral health allows circumpolar health researchers, health systems administrators and policy makers to have a better understanding of the behavioral health problems and actionable solutions for the North. The papers within the ICCH15 Behavioral Health section are representative of the posters and oral presentations of the ICCH15. These papers reflect the continuing evolution of public health practice within the circumpolar north from description of disease and risk factors to a description of strengths and resilience (3), with an emphasis on tackling the social determinates of poor behavioral health. Unlike the papers presented at the ICCH14, few papers at the ICCH15 addressed cultural concepts of behavioral health. The Yupik people of Alaska use the term Yuuyaraq to describe how people should be, how they should interact, how to carry themselves and how to be a positive member of the community (4). Yuuyaraq describes a way of life, including the values of a people. These values are based on where a people comes from as a culture and their place in the circumpolar north. Behavioral health and wellness on an individual level are directly correlated to the health of others according to Yuuyaraq, as is true for other arctic and indigenous peoples. The tension of generalizability to other peoples while being considerate of the ways of being for the community is a very real consideration in circumpolar behavioral health research. The rapid social and environmental changes occurring in the circumpolar north are affecting behavioral health and wellness, and to determine impacts and resilience, it is essential to include cultural constructs of behavioral health alongside clinical and epidemiological descriptions of behavioral health conditions, risk factors, programs and policies. At the ICCH15, we had an opportunity to delve into the process of program development and the considerations of a professional and paraprofessional behavioral health workforce. Behavioral health projects and


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Behavioral Health

research in remote, small communities with co-occurring behavioral health conditions and sequelae require delicate, deliberate planning and implementation. This congress provided an opportunity for researchers and behavioral health practitioners from across the arctic to discuss common difficulties around substance abuse prevention, the compounded effects of historical and situational trauma, and the impact policy changes on behavioral health. Lacking in the papers presented at the ICCH15 Behavioral Health sessions were collaborations across circumpolar nations. Additionally, few papers were presented on the behavioral health of children in the circumpolar north. These gaps could be addressed by researchers seeking collaborative research programs and projects through the International Network for Circumpolar Health Research (INCHR), which has an objective to conduct, sponsor and program research investigating the patterns, determinates and impact of health conditions among circumpolar peoples and the strategies for improving their health (5). The ICCH15 provided a platform for improving and sustaining a circumpolar dialogue on behavioral health issues among the people of the arctic. It is the responsibility of the member organizations of the International Union for Circumpolar Health (IUCH) and emerging circumpolar health organizations such as the INCHR as well as their individual members to keep the collegial

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dialogue moving forward. We will need to continue building and evolving in our partnerships with one another as we meet the challenges we face as the people of the North if we are to successfully improve the behavioral health of our people in the North. Vanessa Hiratsuka Southcentral Foundation Anchorage, AK USA Email: [email protected]

References 1. Boucot KR, editor. The 1967 Symposium on Circumpolar Health Related Problems, July 2328, 1967. Arch Environ Health 1968; 17:457688. 2. Bjerregaard P, Young TK, Curtis T. 35 years of ICCH: evolution or stagnation of circumpolar health research? Int J Circumpolar Health. 2004;63(Suppl 2):239. 3. Orr P. Inuuqatigiitiarniq: living in harmony, through the interconnection of mind, body, spirit and environment. Circumpolar Health Suppl. 2010;7:4234. 4. Napoleon H, Madsen EC. Yuuyaraq. Fairbanks, AK: Alaska Native Knowledge Network, University of Alaska; 1996. 5. Chatwood S, Parkinson A, Johnson R. Circumpolar health collaborations: a description of players and a call for further dialogue. Int J Circumpolar Health. 2011;70:57683.



Survey of northern informal and formal mental health practitioners Linda O’Neill1*, Serena George1 and Stefanie Sebok2 1

Counselling Program, School of Education, University of Northern British Columbia, Prince George, BC, Canada; 2Queen’s University, Kingston, ON, Canada

Background. This survey is part of a multi-year research study on informal and formal mental health support in northern Canada involving the use of qualitative and quantitative data collection and analysis methods in an effort to better understand mental health in a northern context. Objective. The main objective of the 3-year study was to document the situation of formal and informal helpers in providing mental health support in isolated northern communities in northern British Columbia, northern Alberta, Yukon, Northwest Territories and Nunavut. The intent of developing a survey was to include more participants in the research and access those working in small communities who would be concerned regarding confidentiality and anonymity due to their high profile within smaller populations. Design. Based on the in-depth interviews from the qualitative phase of the project, the research team developed a survey that reflected the main themes found in the initial qualitative analysis. The on-line survey consisted of 26 questions, looking at basic demographic information and presenting lists of possible challenges, supports and client mental health issues for participants to prioritise. Results. Thirty-two participants identified various challenges, supports and client issues relevant to their mental health support work. A vast majority of the respondents felt prepared for northern practice and had some level of formal education. Supports for longevity included team collaboration, knowledgeable supervisors, managers, leaders and more opportunities for formal education, specific training and continuity of care to support clients. Conclusion. For northern-based research in small communities, the development of a survey allowed more participants to join the larger study in a way that protected their identity and confidentiality. The results from the survey emphasise the need for team collaboration, interdisciplinary practice and working with community strengths as a way to sustain mental health support workers in the North. Keywords: northern; mental health; informal and formal practitioners; research

esearch and information on northern mental health practice in Canada is limited, and what is available comes from the professions of social work and nursing. The challenges faced in the delivery of mental health and wellness support in the North are better understood through this profession-specific research (1). Yet the situation of both formal and informal practitioners who provide mental health support throughout northern Canada is scarce. Lay counsellors, drug and alcohol counsellors, community counsellors, child and youth care workers, elder counsellors, social workers, nurses and other community helpers, both Aboriginal and non-Aboriginal, provide essential psychological and emotional support to clients or family members who live in the North. Previous experience in the North led the research team to use a broad lens and

R

consider the situation of practitioners from many different professions and paraprofessionals from all walks of life in their work of supporting northerners experiencing a broad range of mental health issues. The existing research often focuses on specific professions, such as social work and nursing, who provide various levels of mental health support in northern communities (24). The research team decided to approach mental health support in the North using a more general, inclusive model for recruitment, understanding that much of the supportive work is done by professionals in many helping professions and by informal helpers and paraprofessionals. Informal and formal helping practitioners play a key role in supporting the well-being of community members, and in answering the call to hear more voices from helpers in the field (5), this research


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focused on the localised knowledge of mental health providers throughout the North. The main objective of the 3-year study was to document the situation of formal and informal helpers in providing mental health support in isolated northern communities in northern British Columbia (BC), northern Alberta, Yukon, Northwest Territories (NWT) and Nunavut. In order to better understand mental health and wellness support in the North, the following question informed both the qualitative and quantitative phases of the research: What are the life-career issues, supports, challenges and barriers for formal and informal helping practitioners in northern communities? In northern communities, lack of anonymity and personal privacy is a major challenge. Fundamental issues for isolated practitioners include high visibility with a loss of privacy and anonymity when living and working in small isolated communities (6,7). Northern communities are often locations where people know everyone else in the community whether they want to or not (8). Professionals who come to northern communities often feel as though they are constantly observed and often critically viewed by some community members (2). Separating the practitioner’s personal and professional life and one’s membership in a health system from one’s presence as a new community member in a northern community is extremely difficult (9). In many small northern communities, helping practitioners may be related to other community members. The challenge of confidentiality in northern practice hinges on the difficulty of ensuring client privacy since most community members know each other (10) and informal conversations abound, adding to what Schank and Skovholt (11) refer to as the small world hazards found in helping professions in small communities. The potential of increased isolation of community practitioners is due to their concerns about sharing confidential information. The problems of helping practice in small communities mirror related problems in northern research.

Material and methods Background The multi-method approach used in this multi-year research study involved the use of qualitative and quantitative data collection and analysis methods. Based on previous research (12), the need to protect the anonymity and confidentiality of practitioner participants was foremost in the research development process. Ethical research practice in small northern communities needs to insure participant confidentiality, suggesting acute sensitivity in the writing of the qualitative analysis piece and the need for the development and use of a survey. The intent of developing a survey based on the indepth interviews was to include more participants in the

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research who would be difficult to access for face-to-face interviews due to remote locations, and those working in small communities who would be concerned regarding confidentiality and anonymity due to their high profile within smaller populations. This high profile situation of many helping professionals in small communities forces researchers to take extra steps to ensure confidentiality and anonymity through interviewing participants in communities other than their own, not identifying any communities or specific agencies and by using anonymous survey methods of data collection. We are presenting limited, broad demographics due to our concerns regarding the small population of northern communities and the resultant common problems around assuring confidentiality, especially to those people who provide mental health and wellness services and who may be the only person in the community doing this work.

Research ethics The study received Research Ethics Approval from the University of Northern British Columbia, the University of Lethbridge, a Scientific License from the Yukon Government Department of Tourism and Culture and a Research Licence from the Aurora Research Institute, Aurora College, NWT.

Survey development and analysis Based on the in-depth interviews from the qualitative phase of the project, the research team developed a survey that reflected the main themes found in the initial qualitative analysis completed after each interview by research assistants during 2010 and 2011 (Appendix A). The initial thematic analysis was the framework for the team to develop the key questions on the survey, with the analysis reflecting the main points and concerns from the 20 participants who took part in the in-depth interviews during the qualitative phase of the project (13). In using an initial analysis of qualitative interviews to develop the survey, the intent was to avoid any assumption on the part of the research team that we knew the most relevant topics and appropriate questions that would allow for a greater understanding of the practitioners who provide mental health support throughout the North. Rather, the completed survey presents questions grounded in northern practitioner experience. This on-line survey developed through Fluid Surveys Canada consisted of 26 questions, some looking at basic demographic information and others presenting lists of possible challenges and supports for participants to prioritise. At the end of the survey, a textbox was included for respondents to provide additional information that was relevant, but not necessarily captured in the designed survey questions. All of the data gathered from the on-line survey were exported and descriptive statistics were calculated using


Survey of mental health practitioners

Microsoft Excel. The survey results provided demographic information and descriptive statistics that were analysed in relation to the original qualitative data.

Results Thirty-two northern practitioners, both informal and formal mental health providers, living in northern BC, northern Alberta, Yukon, NWT and Nunavut completed the on-line survey. The sample consisted of 23 females and 9 males, ranging in age from 25 to 58 years of age, with the highest participation from the NWT. Only 2 of the survey participants identified as being Aboriginal (6.25%). This number has significant implications for this study and general practice in the North that will be elaborated on in the conclusion. This sample of mental health supporters surveyed revealed that the average number of communities served by an individual supporter was 2.75, with the largest number of communities served by 1 person being 8. Furthermore, 34% of respondents are presently working on a contract basis. Although some of the practitioners travel to communities, the majority of the respondents live in the community where they work. The range of experience among practitioners varied from less than 1 year to almost 40 years; however, most people reported having 10 years of experience working in the North. One of the most surprising findings was that regardless of the amount of experience participants had, 81% of the practitioners felt prepared for work in northern communities, with this finding directly contradicting some existing research. Table I expands upon this result by illustrating the frequency of factors that contribute to the work of individuals in the North. Knowledge and experience both factored into practitioners view of training. The number of respondents having some level of formal education (91%) may reflect the majority feeling of preparedness for northern mental health work. Other aspects such as work experience, life experience, volunteer work, and mentoring were also listed as essential elements of practitioners training. Practitioners listed communication skills as being the most important personal attribute for northern practice closely followed by empathy, then flexibility and personal awareness. The importance of communication skills

rather than specific therapeutic skills echoes some of the discussion from the qualitative interviews where practitioners described themselves as over trained and having to step back to meet clients where they were currently at a rapport-building stage. The primary way that individuals working in the North feel supported is financially; however, only about half of the respondents felt supported in other ways (i.e. socially, mentally, emotionally, physically, spiritually and culturally). Practitioners identified resources available to them at this time as workspace, training and workshops, and case consultation. Other key resources such as community support, cultural guidance and language interpreters were only reported by the participants approximately 20% of the time. When asked about what resources are essential for mental health supporters working in the North, 75% of respondents listed training and workshops followed by 50% listing mentoring and supervision. Finally, a key area of concern in northern practice is collaboration. The respondents indicated that their main source of collaboration was with their colleagues, health care providers and social services 8090% of the time. Working in the North presents barriers and challenges to mental health support as previously noted. According to the survey respondents, challenges impacting their work included workload and complexity of client issues, geographical and social isolation, and high personnel and staff turnover (53%). The most significant barriers for practitioners in their work included geographical and social isolation and workload, mirroring previous research. Other barriers identified included lack of self-care resources, lack of sustained programme funding and complexity of client issues. In looking at sustained practice and longevity, respondents identified many options for more effective practice, including developing collaborative relationships, working with community strengths, and awareness of both the challenges and the supports available to them in the communities. Supports for longevity agreed upon by respondents included team collaboration, knowledgeable supervisors, managers, leaders, and more opportunities for formal education, specific training and continuity of care to support clients.

Table I. Factors contributing to individuals’ mental health work in the north Questions

First response

Second response

Third response

What training do you have?

Formal education

Work experience

What attributes make you effective?

Communication

Empathy

Life experience Flexibility and personal awareness

In what ways do you feel supported?

Financially

Socially

Mentally and emotionally

What resources are available to you?

Work space

Training

Case consultation

Who do you collaborate with?

Colleagues

Health care providers

Social services


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Table II. Frequency of major client issues as reported by mental health supporters Frequency Issues

(%)

Schizophrenia/Psychosis

28

Disabilities (Physical and Cognitive including

41

FASD) Personality Disorders/Mood Disorders

53

Sexual Assault

56

Psycho-Educational Anxiety Disorders

59 63

Child Abuse

66

Self-Harming Behaviors (Cutting, Burning, etc.)

66

Parenting Issues

69

Depression

72

Suicide

72

Trauma (PTSD, Historical, Intergenerational,

72

Complex) Addictions

78

Crisis Intervention

78

Grief and Loss

78

Table II outlines the type and frequency of issues that mental health supporters provide care for. The following issues listed in Table II highlight major client issues as reported by respondents of the survey. In the face of complicated client issues, practitioners identified codes of ethics, lived experience and standards of practice as being used as their guide in ethical decision making. Despite the strong use of codes of ethics by the practitioners, the respondents suggested that codes related to dual relationships, practitioner competence and confidentiality needed to be changed to reflect northern practice. The practitioners also identified family counselling services, trauma awareness, emphasis on healthy living and mentoring programmes as being the best support services for their clients. The need for family counselling indicated a major lack of such services currently in the North. When asked what provides the motivation for practitioners to continue to provide mental health support in the north, 82% of the practitioners listed commitment to clients as being the main motivator to keep doing the work. Other motivators such as hope, commitment to community, and personal fulfilment were also mentioned by the participants. At the end of the survey, a textbox was included for respondents to provide additional information. In these sections, participants discussed the need for more support and training for Aboriginal paraprofessionals that would be culturally relevant. In line with personal motivation, 1 participant reflected that practitioners really need

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to understand why they are doing the work they do, echoin a theme from the qualitative analysis. Another participant stated that working to shift the doubt and suspicion related to making change took the most energy in practice. The essential need for forming collaborative partnerships where the diverse aspects of helping in northern communities are valued was highlighted by several respondents. The majority of these responses emphasised the importance of interdisciplinary work in northern communities and the differences between providing mental health and wellness support in the North versus providing similar services in more populated southern regions of Canada.

Conclusion Through the safety of an anonymous survey method of data collection, participants were supported in contributing to the larger research project. The survey findings added specific information to the guiding question on the life-career issues, supports, challenges and barriers for formal and informal helping practitioners in northern communities. Information on the complexity of client issues and what supports are currently in place and those that are needed in small communities adds to an improved understanding of what mental health support looks like in the North. Despite the high Aboriginal population throughout the North, the low number of Aboriginal respondents may indicate that this survey tapped into a majority of professionals who at one time came into northern communities from ‘‘outside’’. This result may also indicate hiring criteria for professional mental health positions, reflecting the lack of post-secondary opportunities for northerners living in remote communities. Participants requested more culturally relevant training for Aboriginal support workers, suggesting that there is work to do in all educational endeavours on mental health. The research team will continue to refine research strategies to reach more informal mental health supporters, particularly those of Aboriginal descent. The findings from the survey again emphasise the need for collaboration, supervision, and mentorship in order to better support practitioners and sustain mental health work in the North. The next step will be to find ways to network all people providing mental health support in the North to alleviate the inherent isolation of such work in a northern context.

Acknowledgements The authors and research team thank all participants who took the time to respond to the survey. The authors also thank Jodie Petruzellus for her work on the initial interview analysis that was the basis for the survey. The authors and research team also extend appreciation to the Social Sciences and Humanities Research



Council of Canada (SSHRC) for the funding that made this research possible.


References 1. Graham JR, Brownlee K, Shier M, Doucette E. Localization of social work knowledge through practitioner adaptations in northern Ontario and the Northwest Territories, Canada. Arctic. 2008;61:399406. 2. Schmidt GG. Remote, northern communities. Int Soc Work. 2000;43:337. 3. Tarlier D, Johnson J, Whyte N. Voices from the wilderness: an interpretive study describing the role and practice of outpost nurses. Can J Public Health. 2003;94:1804. 4. Vukic A, Keddy B. Northern nursing practice in a primary health care setting. J Adv Nurs. 2002;40:5428. 5. Waltman GH. Reflections on rural social work. Fam Soc. 2011;92:2369. 6. Green R, Gregory R, Mason R. It’s no picnic: personal and family safety for rural social workers. Aust Soc Work. 2003;56:94106. 7. Munn P, Munn T. Rural social work: moving forward. Rural Society. 2003;13:2234. 8. Rawsthorne M. Social work and prevention of sexual violence in rural communities: the ties that bind. Rural Soc Work. 2003;8:411.

9. Boone M. Strength through sharing: interdisciplinary teamwork in providing health and social services to northern native communities. Can J Commun Ment Health. 1997;16:1528. 10. Galambos C, Watt J, Anderson K, Danis F. Ethics forum: rural social work practice: maintaining confidentiality in the face of dual relationships. J Soc Work Values Ethics. 2006; Available from: http://www.socialworker.com 11. Schank J, Skovholt T. Dual relationship dilemmas of rural and small community psychologists. Prof Psychol Res Pract. 1997;28:449. 12. O’Neill L. The experience of northern helping practitioners. Dissertation. Victoria, British Columbia: University of Victoria; 2008. Available from: http://hdl.handle.net/1828/1009 13. O’Neill L, George S, Koehn C, Shepard B. Informal and formal mental health preliminary qualitative findings. Int J Circumpolar Health. 2013;72. doi: 10.3402/ijch.v72i0.22447. *Linda O’Neill Counselling Program School of Education University of Northern British Columbia 3333 University Way, Prince George BC, V2N4Z9 Canada Email: [email protected]

Appendix A Northern Mental Health and Wellness Survey The first part of this survey provides some general information about you. 1. What is your gender? Male Female Other 2. How old are you? 3. What territory or province do you work in? Yukon NWT Nunavut B.C. 4. What type of applicable education do you have? Formal education (degree, diploma, certified course) Work experience Life experience 5. How many years have you provided mental health support in the North? 6. How many communities do you provide services to?

7. Do you work on a contract basis? Yes No 8. What personal attributes make you effective in your role as a helper? Flexibility Creativity Personal awareness Empathy Communication skills Cultural sensitivity Resiliency Humour 9. What prepared you for this work? Formal education Mentoring Volunteer work Life experience None of the above* 10. Indicate which of the following supports you collaborate with in your work. Colleagues Health care providers Social services


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Law enforcement School personnel Elders Other 11. Do you live in a community where you provide mental health support? Yes No *Branching, if Q8 answer was no* 12. Is adequate housing available to you a community where you live and work? Yes No 13. Given the services you provide, please indicate the ways in which you as a practitioner feel supported. Financially Physically Socially Culturally Mentally Emotionally Spiritually 14. Please indicate the resources that are available to you in your work as practitioner. Training and workshops Financial resources Health services Work space Case consultation Mentoring/supervision Community support Accessible cultural guidance Peer/family support Language interpreters* 15. What are the 3 most important resources necessary for you in this line of work? 16. In what ways are you involved in your community? Volunteer Sports Arts Education Committee work Clubs and organisations This part of the survey asks about what you see as being barriers and supports for formal mental health practitioner. 17. Please indicate which of the following challenges are most applicable to your work. Insufficient training opportunities Racism Isolation (geographical or social) Lack of sustained programme funding Minimal cultural understanding Heavy workload

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Complexity of client issues Limited professional collaboration Poor driving conditions Not enough self-care resources Unmet personal expectations High personnel/staff turnover Language barrier Others, please specify 18. What are the 3 most challenging barriers you face in your work? 19. Which of the following options do you see as practical for making working in the North more effective? Developing collaborative relationships Working with community strengths Living in the community that you work in Accessing external resources (colleagues, friends, professional consultation, etc.) Participating in traditional or non-traditional community practices Tailoring your practice to the needs of the community Awareness of challenges and supports available Increased aboriginal cultural understanding Other 20. What Supports would help you do the work you do longer? More opportunities for formal education/specific training Long-term job security Relief time Increased financial support Knowledgeable supervisor/manager/leader Validation of the services you provide Team collaboration Continuity of care for supporting clients Other 21. Please indicate which of the following issues you provide client support for. Trauma (PTSD, historical, inter-generational, complex) Grief and loss Addictions Depression Anxiety disorders Self-harming behaviors (cutting, burning, etc.) Suicide Sexual assault Personality disorders/mood disorders Schizophrenia/psychosis Parenting issues Child abuse Disabilities (physical, cognitive, including FASD) Psycho-education Crisis intervention



22. Please indicate what support services you feel would best help the clients you work with. Trauma awareness Follow-up support Community activities (community centre) Emphasise healthy living Family counselling services Mentoring Programmes Specific skill development Parent support Alternative education options This part of the survey asks about the motivation and ethics surrounding your work as formal mental health practitioner. 23. What guides your decision making as a formal mental health practitioner? Professional codes of ethics Standards of practice Agency rules and regulations Cultural beliefs and guidelines Spirituality or religion Moral beliefs and values Lived experience 24. What changes would you make to your professional code of ethics that would make it relevant to Northern practice? Confidentiality Practitioner competence Client’s rights

Supervision Dual relationships/boundaries Informed consent Bartering for services Other 25. Please indicate what motivates you to continue to do this work in the North? Sense of duty Commitment to clients Financial reward Advocacy Commitment to the community Community/leadership request Autonomy Personal fulfilment Hope Other 26. Please include any other information that you believe is important to Northern mental health/wellness support. *Linda O’Neill Counselling Program School of Education University of Northern British Columbia 3333 University Way, Prince George BC, V2N4Z9 Canada Email: [email protected]


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Traditional living and cultural ways as protective factors against suicide: perceptions of Alaska Native university students Christopher R. DeCou1*, Monica C. Skewes2 and Ellen D. S. Lo´pez2 1

Department of Psychology, Idaho State University, Pocatello, ID, USA; 2Department of Psychology, Center for Alaska Native Health Research, University of Alaska Fairbanks, Fairbanks, AK, USA

Introduction. Native peoples living in Alaska have one of the highest rates of suicide in the world. This represents a significant health disparity for indigenous populations living in Alaska. This research was part of a larger study that explored qualitatively the perceptions of Alaska Native university students from rural communities regarding suicide. This analysis explored the resilience that arose from participants’ experiences of traditional ways, including subsistence activities. Previous research has indicated the importance of traditional ways in preventing suicide and strengthening communities. Method. Semi-structured interviews were conducted with 25 university students who had migrated to Fairbanks, Alaska, from rural Alaskan communities. An interview protocol was developed in collaboration with cultural and community advisors. Interviews were audio-recorded and transcribed. Participants were asked specific questions concerning the strengthening of traditional practices towards the prevention of suicide. Transcripts were analysed using the techniques of grounded theory. Findings. Participants identified several resilience factors against suicide, including traditional practices and subsistence activities, meaningful community involvement and an active lifestyle. Traditional practices and subsistence activities were perceived to create the context for important relationships, promote healthy living to prevent suicide, contrast with current challenges and transmit important cultural values. Participants considered the strengthening of these traditional ways as important in suicide prevention efforts. However, subsistence and traditional practices were viewed as a diminishing aspect of daily living in rural Alaska. Conclusions. Many college students from rural Alaska have been affected by suicide but are strong enough to cope with such tragic events. Subsistence living and traditional practices were perceived as important social and cultural processes with meaningful lifelong benefits for participants. Future research should continue to explore the ways in which traditional practices can contribute towards suicide prevention, as well as the farreaching benefits of subsistence living. Keywords: Alaska Native; cultural ways; protective factors; suicide; qualitative; interviews

uicide persists as a compelling public health challenge for Alaska Native peoples, and it represents a substantial health disparity for individuals, families and communities in Alaska (1). From 1999 to 2007, the base rate of suicide in the United States was 10.9 deaths per 100,000 people; in contrast, Native peoples in Alaska experienced a rate of 41.3 deaths per 100,000 people (2). Although myriad epidemiological scholarship explicates the magnitude of this disparity (3,4), there is a lack of research exploring specific protective factors against suicide for people living in rural

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communities (1). Nevertheless, it has been suggested that such insights are critical to the development of relevant and effective interventions to address the disparate rates of suicide affecting Alaska Native peoples, and those living in rural and indigenous communities (1,5,6). Traditional ways of life in rural Alaska exemplify robust legacies of resilience, creativity and adaptive responsiveness to emerging challenges (7). The resilience described in this article specifically refers to the ability of Alaska Native peoples to engage in traditional ways of life and important cultural practices, and to concordantly pursue


Cultural ways as protective factors against suicide

progress, achievement and success in Western social, cultural, academic and professional contexts. Previous research highlights the importance of traditional and cultural ways in the development of effective interventions for indigenous communities (810). The embrace and integration of cultural practices (such as subsistence hunting and gathering) within contemporary psychological and public health interventions for critical concerns, including suicide, may portend successful outcomes that go beyond conventional models of treatment and intervention (11). Understanding the strength of traditional ways offers an important path forward for empowering affected stakeholders to address suicidal behavior in tandem with Western research epistemologies. For example, Allen and colleagues (12) described a strengths-based approach to culturally based intervention for suicide and substance abuse, whereby integral systems of traditional living and cultural ways were synthesised to form relevant treatment modalities. These traditional skill sets and cultural knowledge were then applied through collaborative interpretation and application of cultural ways as a metaphor for techniques and strategies that may mitigate problematic behavioral processes, and detrimental sequellae, including suicide (12). The present study sought to qualitatively explore the thoughts, opinions and experiences of rural university students concerning suicide and suicide prevention in rural Alaska. University students who had migrated from rural Alaska to an urban-university setting offered unique perspectives concerning this difficult and sensitive topic. This article specifically reports findings from the analysis of data related to participants’ perceptions of traditional ways and subsistence activities as protective factors against suicide. Understanding affected stakeholders’ perceptions of this synthesis between traditional practices and contemporary suicide prevention efforts is important to the advancement of on-going research and practice within indigenous cultural contexts.

Method Participants This study included a purposive sample of 25 college students who self-identified as being ‘‘from a rural Alaskan village’’. No a priori definition of rurality was prescribed; instead, participants were invited to self-identify as rural based upon their own perceptions of their home communities. Although being Alaska Native was not an inclusion criterion for participation, all participants in the present sample were from Alaska Native ethnic groups. Only students currently enrolled in university classes, and aged 18 years and older were eligible to participate. The majority of participants were female (n 18), ranging in age from 18 to 37 years (M 23.64; SD 4.61).

Participants included students who still considered their home village to be their permanent residence when not attending classes at the university, as well as students who had relocated from their home village 21 years prior to completing an interview (M 4.68; SD5.24). All students self-identified as being Alaska Native and from rural villages with populations, ranging from 70 to 6,500. Almost all participants (n23) reported being from villages where another language was spoken in addition to English. However, all participants were themselves university students who spoke English fluently.

Procedure This study used in-person individual interviews to qualitatively explore participants’ thoughts, opinions and experiences related to the problem of suicide in rural Alaska. Due to the far-reaching impact of suicide in rural Alaska and ethical concerns related to asking participants about their personal experiences related to suicide, the study included a safety plan to address participant distress and provided a list of crisis counselling resources to all participants. However, it is important to note that there were no adverse reactions among participants in the interview study; the safety plan was not needed, and participants reported their experiences to be meaningful and beneficial, despite being difficult (13). Students were offered $50 as compensation for their time and effort. After obtaining informed consent, all participants completed a brief demographics and background questionnaire. The university’s Institutional Review Board approved all methods and materials. The first author conducted most of the interviews (n19), except for those participants (n 6) who requested a female interviewer. The first author had prior training and experience in conducting interviews with survivors of trauma and provided training for the female interviewer prior to her first interview. Preparation for conducting interviews included discussion of interviewer style and setting, rehearsal interviews, discussion of the safety plan and challenges that may arise during an interview. Interview protocol The interviews were conducted using a semi-structured interview guide, developed specifically for this study, in collaboration with cultural and community advisors connected with the university’s rural student community. The interview questions represented a progression through 5 conceptual domains, including background (e.g. What is the best part of life in the community you are from?), ruraltourban transition (e.g. What steps did you have to take to attend college at [University]), suicide in rural Alaska (e.g. In what ways has suicide affected your life?), moving forward (e.g. What is your dream or vision for the future of the community you are from?) and debriefing (e.g. Compared to when you


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arrived, do you feel better, the same, or worse?). This progression allowed the interviewer to establish rapport, understand context, discuss experiences related to suicide and conclude the interview experience with a strengthsbased discussion of the participants’ personal journeys to college. The interviews included open-ended questions, using a non-judgmental and empathic listening style. Interviews lasted an average of 1 hour, and were audiorecorded with participant consent. The interview protocol included specific questions concerning the importance of culture and traditional ways. Given the findings of previous research regarding the centrality and protective value of traditional and cultural ways among Alaska Native Peoples (14), interview questions were phrased to highlight the strength that may arise from buttressing cultural practices. These questions consisted of (a) ‘‘In what ways do you feel most connected to the traditions and heritage of your home village and elders?’’; (b) ‘‘What cultural traditions can be strengthened to prevent suicide?’’; (c) ‘‘How are people able to live healthy lives in the village you’re from?’’; and (d) ‘‘If somebody is depressed in your home community, what could they do to get better?’’

Recruitment Participants were recruited through the use of flyers posted on campus, including student dormitories, academic buildings and the Office of Rural Student Services. Flyers were also distributed through student organisations that specifically serve rural and indigenous students. Posted flyers provided students with basic details about the scope of the study, including the topic of suicide and compensation for participation. Upon contacting the first author, participants were screened for eligibility and offered the choice of scheduling an interview with a male or female interviewer. Unintentionally, snowball sampling also occurred. That is, once data collection began, several participants mentioned being referred by peers who had already completed an interview. Some participants explicitly stated that their intention to complete an interview was to determine whether or not they would recommend the interview experience to other rural students. All reported that they would be referring other rural students. Analysis Members of the research team transcribed the interviews verbatim. Transcripts were de-identified to protect the confidentiality of participants, home villages and others mentioned during the interviews. The interviews were analysed using the techniques of grounded theory (i.e. open-coding and constant comparison) for the purpose of identifying salient themes and concepts within and across participant transcripts (15,16).

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Findings Several key themes emerged from the analysis of transcripts, and they revealed participants’ appreciation of traditional ways and subsistence activities as integral to the unique quality of life in rural communities, as well as central to efforts to prevent suicide. Traditional ways were thought to facilitate important relationships, promote healthy living, contrast with contemporary challenges and communicate important cultural values.

Context of important relationships Participants expressed the importance of family and mentor relationships in the process of mitigating suicide risk and addressing social isolation. Traditional ways and subsistence activities represented an important avenue for those relationships and appeared to position key relationships within community, familial and dyadic contexts. That is, traditional ways integrated critical social processes within tight knit villages across multiple ecological levels. As 1 participant explained concerning relationships among community members: The best part of life, I grew up there, and I liked it very much, pretty much livin’ the cultural ways, bein’ able to still do those cultural things, like subsistence living, Native dancing, and stuff like that. And they have celebrations every other fall for families who have family members that are deceased, and they throw potlatches, and that’s a way to get the community together and to get them sharing, and just being involved, and stuff like that. (P08)

In addition to contextualising relationships among community members, traditional hunting and gathering activities represented a central experience within families for many participants. One participant explained the transgenerational importance of annual subsistence activities for their family: I was pretty much raised by my parents and my grandparents, my maternal grandparents, we would go camping every August for a week, pick berries, and while we’re picking berries the men would trap, we’d eat fish and drink tundra tea, and just living, the way our ancestors did. (P06)

Another participant explained the instructive role of their mother in supporting connection with elders, who represent important mediators of cultural knowledge and traditions: ‘‘My mom used to make me visit Elders in [home village], I’m glad she did, um, and they were cool folks, the ones I used to visit.’’ (P05)

Promotes healthy living to prevent suicide In addition to the meaningful relationships integral to traditional ways and subsistence activities, participants also identified the ways in which these cultural practices promote healthy living. In this way traditional practices


Cultural ways as protective factors against suicide

and subsistence activities represented a means by which the antecedents of suicidal behavior (e.g. depression) might be attenuated. One participant described access to Native foods as a way to pursue health within the context of a village community: ‘‘I guess healthy eating, we have fish, we have a lot of fish. Like I said, there is some subsistence fishing, people go hunting so there’s fresh meat. I guess that’s one aspect of healthy living’’ (P07). In addition to traditional foods, participants also explained the importance of interaction with nature, and experiences involving tribal and village lands. One participant described a nature walk as a way to be healthy within a rural context: I would suggest more nature walks . . . Just walking up the hill, like all the way up. It gets really windy, but then like it takes like an hour to walk all the way up, maybe hour and a half, and take a camera, take pictures, pick flowers, I think that’s how they could be more healthy. (P06)

It is important to note that these recommendations for healthy living occurred within the context of participants’ responses to interview questions specific to the problem of suicide in rural Alaska.

Contrast with current challenges Although participants described the importance of cultural ways, they also expressed their perceptions of a schism between traditional ways and modern lifestyles in rural communities. One participant shared their observation concerning these changing paradigms: I think that a healthy lifestyle would be like back in the old days, where there was no alcohol, no drugs, no disrespect, and livin’ off only the land, and think that would be like the healthiest lifestyle to live in the villages . . . because people back then would respect everything and everyone more than now. (P10)

In addition to perceived changes in the relationships between people and natural resources, participants also described their observations concerning changes in family relationships. This participant observed a decrease in the relationships between children and grandparents, and concordantly identified diminished participation by children in subsistence activities: There was that tie between the young children and the grandparents that I don’t see too much anymore. You see it in select families and those are the families you feel like are the more healthy ones. But, it seems like now, all the young generation kids, they don’t want to spend time doing anything subsistence. (P03)

Communicate important cultural values In addition to facilitating the contexts of relationships, participants described traditional ways and subsistence

activities as cultural metaphors necessary for passing cultural knowledge from one generation to the next, particularly in rural communities. One participant described the multiple layers of practical importance and transmission of cultural values associated with subsistence activities: It’s a way of life that you can pass down to your children, in a way that you can’t in the city or in a small town . . . not only are you passing down how to hunt and fish but you’re also teaching different family morals as well. (P01)

Participants explored cultural values in nuanced ways that recognised the changing realities of rural Alaska, and concurrently highlighted the need to support and communicate values in a sustainable way. One participant described their idea to instil and support traditional cultural values, including the integration of subsistence: I had the idea of bringing back the [tribal] values, like from back when people used to rely on each other and respect each other. There’s the language and there’s subsistence and I don’t think we’re gonna bring back the spirit world but we can bring back respect. (P10)

Although many participants described the decline of traditional values within rural communities, they remained hopeful about the potential for reclaiming and re-appropriating these cultural ways to address health concerns, such as suicide. One participant described the potential for instilling the value interdependence among youth through the use of traditional dance and languages: I think if they, if we, tried to strengthen the language and our Native dance it would bring the community more together, and um, the youth would be involved a lot, and they’d know from a younger age that they’re a part of something, and, um, they’d have people to lean on if they needed. (P18)

Discussion Taken together, participants’ perceptions of traditional ways and subsistence activities represent a synthesis of relationships, health and culture. Participants viewed traditional ways as meaningful and beneficial aspects of rural living with potential applications to intervention and prevention strategies for individuals, families and communities. The findings of this article are commensurate with previous research conducted with Alaska Native and indigenous peoples (8,9,12,17) and offer additional insight into the perceptions of affected stakeholders. Specifically, these findings explicate participants’ perceptions of traditional and cultural ways as protective against suicide, and support the imperativeness of additional research to evaluate the benefits of framing suicide prevention efforts within the strengths and resilience of Alaska Native


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Peoples. However, it is important to consider the limitations of the present findings.

Limitations The findings presented in this article emerged from interviews with Alaska Native students who self-selected to participate in this study. It is possible that these participants are not representative of other rural and indigenous students in Alaska, and they may be substantially different from those students choosing not to participate in a study they knew would discuss the topic of suicide. Moreover, the selection bias that limits these findings may be more pronounced given the unintentional snowball sampling that occurred. It is also important to consider the potential limitation that may arise from underestimating heterogeneity within the specific cultural groups and regions represented within our sample of Alaska Native university students. Indeed, our participants represented a diversity of rural and indigenous communities across the State of Alaska.

Conclusion Traditional ways and subsistence activities were perceived as important aspects of participants’ experiences, and considered protective against suicide. Participants described the changing nature of rural communities, and possible challenges to the sustainability of these cultural practices. However, participants remained hopeful that concerted efforts could promote the continued integration of traditional ways and subsistence activities within contemporary efforts to address the problem of suicide in rural Alaska. Additional research should include quantitative and prospective methods to determine the extent to which the inclusion of cultural and traditional ways in treatment and prevention may yield advantageous outcomes beyond Western models of health and healthcare alone.

Conflict of interest and funding Research reported in this publication was supported by the National Science Foundation and Alaska EPSCoR under grant EPS-0701898, and by the National Institute of General Medical Sciences of the National Institutes of Health under award number P30GM103325. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National institutes of Health.

References 1. Allen J, Levintova M, Mohatt G. Suicide and alcohol-related disorders in the U.S. Arctic: boosting research to address a primary determinant of health disparities. Int J Circumpolar Health. 2011;70:47387. 2. WISQARS: Web-based Injury Statistics Query and Reporting System. CDC: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2003 [cited 2012 Nov 10]. Available from: www.cdc.gov/ncipc/ wisqars

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3. Perkins R, Sanddal TL, Howell M, Sanddal ND, Berman AL. Epidemiological and follow-back study of suicides in Alaska. Int J Circumpolar Health. 2009;68:21224. 4. Mackin K, Perkins T, Furrer C. The power of protection: a population-based comparison of Native and non-Native youth suicide attempters. Am Indian Alsk Native Ment Health Res. 2012;19:2054. 5. Goldston DB, Davis Molock S, Whitbeck LB, Murakami JL, Zayas LH, Nagayama Hall GC. Cultural consideration in adolescent suicide: prevention and psychosocial treatment. Am Psychol. 2008;63:1431. 6. Wexler L, Silveira ML, Bertone-Johnson E. Factors associated with Alaska Native fatal and nonfatal suicidal behaviors 2001 2009: trends and implications for prevention. Arch Suicide Res. 2012;16:27386. 7. Kawagley AO. A Yupiaq Worldview: a pathway to ecology and spirit, 2nd ed. Prospect Heights, IL: Waveland Press; 2006. 8. Mohatt NV, Fok CCT, Burket R, Henry D, Allen J. Assessment of awareness of connectedness as a culturally-based protective factor for Alaska Native youth. Cultur Divers Ethnic Minor Psychol. 2011;17:44455. 9. Wexler L. Behavioral health services ‘‘Don’t work for us’’: cultural incongruities in human service systems for Alaska Native communities. Am J Community Psychol. 2011;47: 15769. 10. EchoHawk M. Suicide: the scourge of Native American people. Suicide Life Threat Behav. 1997;27:607. 11. Mohatt GV, Rasmus SM, Thomas L, Allen J, Hazel K, Marlatt GA. Risk, resilience, and natural recovery: a model of recovery from alcohol abuse for Alaska Natives. Addiction. 2008;103:20515. 12. Allen J, Mohatt GV, Rasmus SM, Two Dogs R, Ford T, Iron Cloud Two Dogs E, et al. Cultural interventions for American Indian and Alaska Native youth: the Elluam Tungiinun and Nagi Kicopi programs. In: Spicer P, Farrell P, Sarche M, Fitzgerald HE, editors. Child psychology and mental health: cultural and ethno-racial perspectives, American Indian child psychology and mental health, Volume 2: prevention and treatment. New York: Praeger; 2011, p. 33764. 13. DeCou CR, Skewes MC, Lo´pez EDS, Skanis ML. The benefits of discussing suicide with Alaska Native college students: qualitative analysis of in-depth interviews. Cultur Divers Ethnic Minor Psychol. 2013;19:6775. 14. Allen J, Mohatt GV, Rasmus SM, Hazel KL, Thomas L, Lindley S. The tools to understand. J Prev Interv Community. 2008;32:4159. 15. Corbin J, Strauss A. Basics of qualitative research: techniques and procedures for developing grounded theory, 3rd ed. Thousand Oaks, CA: Sage; 2008. 16. Charmaz K. Constructing grounded theory: a practical guide through qualitative analysis. Thousand Oaks, CA: Sage; 2006. 17. Allen J, Mohatt G, Fok C, Henry D, People Awakening Team. Suicide prevention as a community development process: understanding circumpolar youth suicide prevention through community level outcomes. Int J Circumpolar Health. 2009;68:27491. *Christopher R. DeCou Department of Psychology Idaho State University 921 S. 8th Ave., Mail Stop 8112 Pocatello, ID, 83209-8112 USA Email: [email protected]



Prenatal alcohol exposure among Alaska Native/American Indian infants Burhan A. Khan*, Renee F. Robinson, Julia J. Smith and Denise A. Dillard Southcentral Foundation, Anchorage, AK, USA

Background. Recent reports indicate a decline in rates of Fetal Alcohol Syndrome (FAS) among Alaska Native and American Indian (AN/AI) infants. Nevertheless, AN/AI infants remain disproportionately impacted by the effects of prenatal alcohol exposure. Methods. AN/AI pregnant women in their 3rd trimester completed a questionnaire on demographic data and the amount and frequency of their alcohol consumption in the month prior to conception and during pregnancy. Differences across demographics and trimesters were tested with the Chi-square, Fisher’s exact or McNemar’s test as appropriate. Results. Of the 125 participants, 56% (n 71) reported no alcohol consumption in the 1st through 3rd trimesters of pregnancy; 30% (n 38) of the 125 participants also reported no alcohol consumption in the month before pregnancy. Of the 43% (n 54) who reported consuming alcohol during pregnancy (1st, 2nd and/or 3rd trimester), most (35%) reported alcohol use only in the 1st trimester. Binge drinking in the 1st or 2nd trimester was reported amongst 20% (n 25) of participants with an additional 18% (n 29) reporting binge drinking in the month prior to pregnancy. Women who reported pre-conception binge drinking were significantly more likely to report binge drinking during their 1st trimester (pB0.0001) and 2nd trimester (p B0.0001). A history of tobacco use (p 0.0403) and cigarette smoking during pregnancy (p B0.0001) were also associated with binge drinking during pregnancy. Conclusion. Among study participants, reported use of alcohol was primarily limited to pre-conception and the 1st trimester, with a dramatic decrease in the 2nd and 3rd trimesters. Prevention programmes, such as the Alaska FAS Prevention Project, may have contributed to observed decreases in the 2nd and 3rd trimesters. Additional study and focus on pre-conception, the 1st trimester and binge drinking, as well as tobacco use might augment Fetal Alcohol Spectrum Disorder prevention efforts. Keywords: prenatal alcohol exposure; fetal alcohol syndrome; fetal alcohol spectrum disorder; Alaska Native/American Indian infants

lcohol use during pregnancy, or prenatal alcohol exposure (PAE), is a national concern, as alcohol use can negatively impact a woman’s health and can be passed across the placenta to a developing foetus. Alcohol abuse during pregnancy poses risks to the foetus (including poor growth, decreased muscle tone, delayed development, heart defects, physical/structural problems and mental retardation) known as Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Spectrum Disorder (FASD) (1). FAS is the term used to describe growth, mental and physical problems that may occur in an infant when a mother consumes alcohol during pregnancy, whereas FASD is the term used to describe the additional direct and indirect social, physical and emotional effects (24).

A

FAS is one of the most preventable causes of mental retardation in the United States (1,5). Annual long-term economic and societal costs associated with FAS and FASD are in the billions (24,6). In 2002, Alaska was assessed as having the highest FAS prevalence rates in states using similar surveillance methodologies (1,712). Between 1996 and 1998, FAS prevalence was 15-fold higher in the Alaska Native population than the general Alaska population (13). Though this discrepancy has since decreased, Alaska Native infants still have a disproportionally higher prevalence of FAS with 32 Alaska Native infants with FAS compared to 6 NonNative Alaskan infants with FAS per 10,000 live births between 2000 and 2002 (14).

This article is based on an article that was featured in the IHS Primary Care Provider (September 2011).


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Abstinence from alcohol has been recommended for women who are pregnant or may become pregnant. However, based on studies in the general population, prenatal abstinence from alcohol is estimated to be low (B20% of pregnant women are abstinent in the 1st trimester) (15). No ‘‘safe’’ level of alcohol use during pregnancy has been established, and prevalence of alcohol use among pregnant and non-pregnant women of childbearing age continues to be a concern. However, larger amounts of alcohol and binge alcohol drinking (currently defined for women as ]4 drinks per sitting) appear to be more harmful than smaller amounts of alcohol ingestion (16,17). Despite increased education and delays in age of conception, drinking behaviors do not appear to have significantly changed (18). During 20012005, the highest percentages of pregnant women in the United States reporting any alcohol use were women aged 3544 years (17.7%) and women with college degrees (14.4%) (19). Alcohol ingestion in pregnant Alaska Native/ American Indian (AN/AI) women is an even greater public health concern than the general US population (13,2022). Given high rates of self-reported alcohol use in adults and the high prevalence of FAS and FASD in AN/AI infants, understanding alcohol intake habits of AN/AI pregnant women is vital to develop targeted prevention strategies (1,712). As FASD among infants is a direct result of PAE among pregnant women, there is a need to better identify, document and understand alcohol consumption of AN/AI women during pregnancy (e.g. exposure to alcohol through over-the-counter medications, absolute alcohol consumption and occurrence of binge drinking). In this study, we assess self-reported PAE among AN/AI women.

Methods Setting Southcentral Foundation’s Primary Care Center (SCFPCC) in Anchorage, Alaska, provides pre-paid primary care services to approximately 45,000 eligible AN/AI people in the urban and remote rural surrounding areas of Anchorage. Recruitment Any AN/AI woman ]21 years of age, in her 3rd trimester of pregnancy, and eligible for care at the SCFPCC was eligible to participate in the study. Questionnaire After consent, women were asked to complete a detailed questionnaire on alcohol exposure for each trimester of pregnancy and the month prior to pregnancy. Participants identified both the month in which they found out they were pregnant (received a positive pregnancy test) and the month of their 1st prenatal visit. Based on

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answers to these questions, the recruiter determined the month prior to pregnancy, 1st trimester, 2nd trimester and 3rd trimester. If consumption of beverages containing alcohol was reported, additional questions about alcohol type, frequency of consumption and amount consumed were asked. Women were also asked about their alcohol consumption during the month before pregnancy and each trimester. The 9 types of alcoholic beverages assessed were beer, malt liquor, wine, sweet wine, fortified wine, wine coolers, hard liquor, mixed drinks and liqueurs. Questions regarding age, height, weight (before pregnancy) and smoking status were also included on the questionnaire.

Data collection and categorisation De-identified questionnaire data were entered and verified using QDS 2.5 software (Bethesda, MD). Daily absolute alcohol values were calculated from participants’ responses to type and volume of alcohol by adjusting reported ounces consumed per day to a number of standardised drinks and multiplying by 0.5 ounces of absolute alcohol per standardised drink. For example, 4 ounces of wine represented a standardised drink and thus represented consumption of 0.5 ounces of absolute alcohol. Categorisation of absolute alcohol consumption was adapted from prior studies with B0.01 fluid ounce (fl. oz.) per day, indicating abstinence from alcohol (i.e. B12 drinks a year), 0.010.21 fl. oz. per day indicating light drinking (i.e. B3 drinks a week), 0.221.00 fl. oz. a day indicating moderate drinking (i.e. 314 drinks per week), and 1.00 fl. oz. a day indicating heavy drinking (i.e. 14 drinks per week) (23,24). At the time of the study, binge drinking was defined as ingesting 5 or more drinks in one sitting, and thus was assessed as such on the questionnaire (16,2527). It should be noted that since the time this study was conducted, the definition of female binge drinking has been reduced from ]5 drinks to ]4 drinks in one sitting, according to the National Institute of Alcohol Abuse and Alcoholism (NIAAA). Data analysis Statistical analyses were performed using SAS 9.2 software (Cary, NC). Associations with reported drinking were investigated with the Chi-square Test of Proportions or Fisher’s Exact Test when appropriate. Associations of reported drinking between time periods were tested with McNemar’s Test. P-values B0.05 were considered significant.

Results Demographics Over the course of the recruiting period, 125 AN/AI pregnant women were enrolled into the study. The average age of participants was 26.8 years of age, with a range of 2139 years of age.


Alaska Native infants

Reported drinking during pregnancy Of the 125 participants, 43% (n54) reported drinking alcoholic beverages during pregnancy (1st, 2nd and/or 3rd trimester), with 35% (n 44) reporting alcohol use in the 1st trimester only. The remaining 8% (n 10) reported alcohol use in time periods other than the 1st trimester. Of the 80 women who reported alcohol use for the month prior to pregnancy, 59% (n47) reported drinking during pregnancy. Of the 71 women that reported no alcohol use during the 1st, 2nd and 3rd trimesters, 54% (n 38) reported alcohol use in the month prior to pregnancy. Thirty percent (30%) of the total participant pool (n 38) reported no alcohol consumption from the month before pregnancy through the 3rd trimester. The most prevalent types of alcoholic beverages consumed during pregnancy were beer (23.2%), mixed drinks (21.6%), hard liquor (18.4%) and wine (16%) (Fig. 1).

reported binge drinking in the 3rd trimester. Demographics of women reporting binge drinking are detailed in Table I. Although age was not associated with binge drinking during the month before pregnancy (p0.4288), a higher percentage of women in the youngest age category reporting binge drinking compared to the older categories during pregnancy, though this relationship was not statistically significant (p 0.0544). History of tobacco use (p0.0403) and smoking tobacco use during pregnancy (p B0.0001) were also associated with binge drinking during pregnancy. However, body mass index was not associated with binge drinking before or during pregnancy. Importantly, women who reported binge drinking during the month before pregnancy were significantly more likely to report binge drinking during their 1st trimester (pB0.0001) and 2nd trimester (pB0.0001, data not shown).

Absolute alcohol consumption Daily reported absolute alcohol consumption was compared by trimester and the month prior to pregnancy (Fig. 2). Over the course of the pregnancy, daily values of absolute alcohol consumption decreased heavily between the 1st and 2nd trimesters, with the majority of participants fitting into the abstinence category for the 2nd and 3rd trimesters. Average daily absolute alcohol consumption decreased over the duration of reporting period from 0.371 fl. oz. (month before) to 0.055 fl. oz. (1st trimester) to 0.004 fl. oz. (2nd trimester) to 0.001 fl. oz. (3rd trimester).

Discussion

Binge drinking Twenty percent (n25) of participants reported at least 1 occurrence of binge drinking during the 1st or 2nd trimester, with an additional 18% (n 29) reporting binge drinking in the month prior to pregnancy. No women

In our study, self-reported alcohol use among AN/AI women during pregnancy ( 50%) continues to be higher than in the general population. Reported drinking was primarily limited to pre-conception and the 1st trimester, with a dramatic decrease in the 2nd and 3rd trimesters. Prevention programmes, such as the Alaska FAS Prevention Project, may have contributed to noticeable decreases, especially in the 2nd and 3rd trimesters; however, alcohol exposure during pre-conception and during the 1st trimester remains high and of concern. Binge drinking pre-conception was also associated with binge drinking in the 2nd trimester and during the entire pregnancy. Thus, additional study focused on preconception, the 1st trimester and binge drinking might augment FASD prevention efforts among AN/AI women (7,10,15,28,29). For instance, providers could be encouraged to routinely discuss childbearing plans with women

Fig. 1. Type of alcohol ingested during pregnancy (percentages of cohort). Citation: Int J Circumpolar Health 2013, 72: 20973 - http://dx.doi.org/10.3402/ijch.v72i0.20973

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100% 90%

Percentage of Study Cohort

80% 70% 60% Heavy Moderate Light Abstainer

50% 40% 30% 20% 10% 0% Month Before Pregnancy

1st Trimester 2nd Trimester Time Period

3rd Trimester

Fig. 2. Daily absolute alcohol consumption categorisations by trimester.

Table I. Demographics and predicative comparisons for binge drinking during pregnancy and the month prior to pregnancy Pregnancya

Month before pregnancy Yes Binge drinking (125 Surveys)

No

Yes

n

%

n

%

22 19

42.31 33.33

30 38

57.69 66.67

pb

No

n

%

n

%

15 7

28.85 12.28

37 50

71.15 87.72

22

36.07

39

63.93

3

4.69

61

95.31

pb

Demographics Age (16 missing) 2125 years 26 years

0.4288

0.0544

Smoking during pregnancy or month prior (2 missing) Yes

36

59.02

25

40.98

No

14

21.88

50

78.13

11

34.38

21

65.63

8

29.63

19

70.37

16

41.03

23

58.97

B0.0001

B0.0001

Body Mass Index (27 missing) Underweight/normal weight Overweight Obese Predictive comparisons

0.6198

6

18.75

26

81.25

5

18.52

22

81.48

8

20.51

31

79.49

1.0000

Binge drinking during 1st trimester Yes

20

83.33

4

16.67

No

30

29.70

71

70.30

21

84.00

4

16.00

29

29.00

71

71.00

Binge drinking during pregnancy Yes No

B0.0001

a

B0.0001

a

Includes reported drinking in 1st, 2nd and/or 3rd trimester. Demographics comparisons used Chi-square test of proportions unless cell counts were too small in which case Fisher’s exact test was used. Predictive drinking comparisons used McNemar’s Test. Significant p-values in bold.

b

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Alaska Native infants

they serve and then encourage abstinence from alcohol among women as they try to become pregnant or among sexually active women without effective contraception. Such efforts may potentially attenuate alcohol use very early in the 1st trimester when women may not know they are pregnant. Since all drinks do not contain the same amount of alcohol, data were collected to identify the type and quantity of beverage ingested. In our study, absolute ethanol consumption was quite variable and ranged from 0 to 237.5 fl. oz. per trimester (Fig. 2) and included a variety of drinks (Fig. 1). Efforts to better identify and understand consumption habits of AN/AI women during pregnancy are vital for targeted PAE prevention strategies. Providers should review with pregnant women the risks associated with ingesting alcohol, making note of the risks associated with different types and volumes of drinks (20,30). Binge drinking is particularly harmful to foetal brain development (19). In this study, we found significant preconception binge drinking, and we found pre-conception binge drinking to be strongly associated with binge drinking during the 1st trimester (Table I). Given the current lowered threshold for binge drinking to ]4 drinks in 1 sitting, estimates of binge drinking we present may be underestimating the prevalence according to current definitions. Younger women were more likely to binge drink (Table I), suggesting a need for more screening and FAS education of women of childbearing age and during early pregnancy. According to a nationwide, postpartum survey, 42.5% of all Alaskan women having a live birth reported the pregnancy was either mistimed (32.4%) or not planned (10.1%). Contraceptive use among these women was reported at 45.3%. Considering these percentages and the prevalence of pre-conception binge drinking in our cohort, healthcare providers should encourage abstinence from alcohol among Alaska Native women who may become pregnant, whether using contraception or sexually active and not using contraception. Efforts can be targeted at younger women, as they were more likely to continue binge drinking into their pregnancy. Future research to identify Alaska Native women’s views regarding pregnancy may help establish appropriate pregnancy planning programmes and further understanding of social and/or cultural characteristics affecting pregnancy. Chang et al. has developed and tested a 4-item alcohol exposure screening tool proven to be more sensitive during pregnancy than typical obstetric staff assessment in ethnically diverse populations (29). Based on our data, this screening tool may be useful to identify women at increased risk in the AN/AI population. In addition, the questionnaire used did not differentiate between alcohol exposure very early in the 1st trimester when women may not know they are pregnant versus

alcohol exposure later in the 1st trimester. Furthermore, as women were recruited in the 3rd trimester, recall of alcohol ingestion in the 1st and 2nd trimesters may not have been accurate. Another limitation to our study was sample size. Our study achieved a quarter of the original recruitment goal. A prenatal tobacco exposure study recruiting in parallel with this study enrolled 3-times as many participants. This observation suggests a reluctance of AN/AI pregnant women to enrol into prenatal alcohol-related studies. Social stigma associated with drinking during pregnancy may have been a barrier in achieving the original recruitment goal and thus attaining an even more representative participant population of pregnant AN/AI women. Finally, another limitation to our study was the age of the respondents. Based on the legal drinking age, we decided to look at women aged 21 years and older. This may underestimate the impact of underage drinking on the prevalence of FAS in the AN/ AI community.

Conflict of interest and funding This study was supported by a Native American Research Centers for Health (NARCH) grant U26IHS 300012 from the Indian Health Service with the support of National Institutes of Health/National Institute of Alcohol Abuse and Alcoholism. The authors have not received any funding or benefits from industry to conduct this study.

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Distance education for tobacco reduction with Inuit frontline health workers Rob Collins1*, Merryl Hammond1, Catherine L. Carry2, Dianne Kinnon3, Joan Killulark4 and Janet Nevala5 1

Consultancy for Alternative Education, Montreal; 2Former senior program officer, Inuit Tuttarvingat, National Aboriginal Health Organization, Ottawa; 3Former director, Inuit Tuttarvingat, National Aboriginal Health Organization, Ottawa; 4Department of Health and Social Services, Nunavut; 5Nevala Consulting, Ottawa

Background. Tobacco reduction is a major priority in Canadian Inuit communities. However, many Inuit frontline health workers lacked the knowledge, confidence and support to address the tobacco epidemic. Given vast distances, high costs of face-to-face training and previous successful pilots using distance education, this method was chosen for a national tobacco reduction course. Objective. To provide distance education about tobacco reduction to at least 25 frontline health workers from all Inuit regions of Canada. Design. Promising practices globally were assessed in a literature survey. The National Inuit Tobacco Task Group guided the project. Participants were selected from across Inuit Nunangat. They chose a focus from a ‘‘menu’’ of 6 course options, completed a pre-test to assess individual learning needs and chose which community project(s) to complete. Course materials were mailed, and trainers provided intensive, individualized support through telephone, fax and e-mail. The course ended with an open-book post-test. Follow-up support continued for several months post-training. Results. Of the 30 participants, 27 (90%) completed the course. The mean pre-test score was 72% (range: 3898%). As the post-test was done using open books, everyone scored 100%, with a mean improvement of 28% (range: 262%). Conclusions. Although it was often challenging to contact participants through phone, a distance education approach was very practical in a northern context. Learning is more concrete when it happens in a real-life context. As long as adequate support is provided, we recommend individualized distance education to others working in circumpolar regions. Keywords: Inuit; health workers; distance education; self-directed learning; tobacco reduction; Canada

he purpose of this intervention was to use distance education with at least 25 frontline health workers from all Inuit regions of Canada (Inuit Nunangat) to help them reduce tobacco use in their communities. Health Canada funded this project.

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Context There are 4 regions in Inuit Nunangat, from west to east: the Inuvialuit Settlement region with 6 communities; Nunavut with 26 communities; Nunavik with 14 communities; and Nunatsiavut with 6 communities. In almost all cases, these remote communities are not accessible by road. Population sizes according to 2011 census data vary from very small (from approximately 100 to 300), to medium (400 to 800), to large (up to 6 or 7,000 in the

case of the largest regional/territorial capital). The vast majority of residents are Inuit/Inuvialuit. In almost all communities, one or more Inuit/Inuvialuit lay health workers overwhelmingly females have been hired to work as community health workers. Some have received formal training; others have not. Most remain on the job for many years, assisting the nurse(s) in the clinic and doing health promotion work in the community. It was this category that we targeted for this intervention. To simplify, we refer to them as community health representatives (CHRs), even though they are known by different titles, such as community health workers, community wellness workers and so on. Many CHRs are themselves smokers, and as a result have been reluctant to do tobacco reduction work in their communities.


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Motivation: the need for an intervention Why tobacco reduction? Tobacco reduction is of major concern to health practitioners and policy-makers globally (112). Given the higher rates of smoking in Aboriginal communities, tobacco reduction is of particular concern to people working in these communities (1327). This applies equally to health workers in Inuit communities in Canada. In the 1990s, 1 in 3 deaths in the former Northwest Territories (which includes what is now Nunavut) was attributable to smoking (28). Lung cancer rates for both Inuit women and men in Canada are the highest in the world (29), and a reduction in cancer rates would make the largest contribution to an increased life expectancy in Inuit Nunangat compared to the rest of Canada (30). Apart from cancer, tobacco use also contributes to increased rates of heart disease, stroke, respiratory illness and complications of pregnancy (22). Jenkins et al. (31) found that 85% of Inuit mothers in Iqaluit, Nunavut reported that they had smoked during pregnancy, and 94% of infants were exposed to tobacco smoke in the home. Smoking is the single greatest preventable contributor to death, disease and disability for Inuit. Despite this, smoking reduction is often neglected due to more immediate health crises or new funding priorities. This project aimed to keep tobacco reduction on the public health agenda in the communities from which participants were selected. Why distance education? Access to post-secondary educational opportunities is very difficult for learners living in remote regions (32). Many CHRs are responsible for child- and/or elder-care in their families. It is much more practical for them to stay home rather than travel long distances (at high cost to the employer, in often unreliable weather conditions) to attend face-to-face workshops. In addition, as distance learners, they can stay on the job, taking a few hours off for telephone calls and project work related to their studies, instead of being absent for days or even weeks at a time, and having to be replaced at work. Also, studying by distance education enables participants to integrate their learning into their everyday work and undertake practical projects in the community, rather than being isolated in a workshop away from the reality of the community health problems they wish to address. There are, however, several barriers to be overcome in distance education programmes, one of which is high dropout rates. Hamilton et al. (33) had ‘‘active participation’’ from only 46%, ‘‘less active participation’’ from 24%, and non-participation from 30% of the 96 Inuit students who registered for an on-line nutrition course. (Note: The target students for their course were educationally, occupationally, socially and culturally very

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similar to those in this intervention.) Language and cultural barriers for Inuit students studying in English, work pressures and geographic isolation of students were other issues to be considered in both this case and the Hamilton study. Using distance education that includes intensive, on-going support with Inuit adult learners has worked very well in a similar program where 81% of participants completed the course, thus confirming the potential of culturally affirming and learner-supportive distance education in Inuit Nunangat (34).

Why a self-directed approach to learning? The trainers (RC & MH) had had positive prior experience using self-directed learning with distance learners in a course for primary health-care educators in South Africa (35). They therefore recommended this approach for the current intervention. Self-directed learning addresses differences in previous training, levels of education and experience, and variations in working conditions of frontline health workers. Learners identify their own learning needs and customize their learning to meet those needs. There is a flexible timetable and structure to accommodate the varied circumstances of participants from different regions across Canada. Review of tobacco reduction literature and resources In 2010, Inuit Tuttarvingat of the National Aboriginal Health Organization contracted RC & MH to conduct a review of relevant literature, resources and promising practices for the Inuit Tobacco-free Network, a national group working to reduce tobacco use in Inuit communities. The report (36) ensured that preparations for the planned distance education course in tobacco reduction were fully informed by practices of possible relevance to Inuit practices that were found to be promising with various populations (with a focus on Aboriginal communities) in Canada and globally. The review confirmed that many promising practices in tobacco reduction were already being implemented in Inuit regions. Successful programmes tend to have a community rather than individual orientation, use materials and approaches that have a high degree of relatedness to the culture and community, and continue over several years. A summary of the comprehensive literature review, titled What Works in Reducing Tobacco Use in Indigenous Communities? A Summary of Promising Practices for Inuit (37), was produced in 3 dialects of the Inuit language, English and French, and this was distributed to course participants, partners and other stakeholders. The comprehensive report (36) was web-published after the course.


Distance education for Inuit health workers

The distance education course The National Inuit Tobacco Task Group (Advisory Group) The Advisory Group consisting of stakeholders, elders and experts from across Inuit Nunangat guided this project. Up to 10 members simultaneously joined teleconference calls to give feedback on draft materials, and 20 local supervisors, usually the nurse-in-charge, and 5 managers from regional/territorial health departments also assisted. Trainers Two experienced trainers (non-Inuit, but who had both worked in Inuit communities for many years) helped design and implement the distance education course and provided follow-up support after the project ended. Recruitment of participants Inuit regional and territorial health authorities, nongovernmental organizations, hamlet councils, health centres and CHRs in almost every Inuit and Inuvialuit community were contacted to support the project and to help recruit participants. Telephone and/or e-mail contact was established with everyone on a list of 33 potential recruits. Three people declined to participate, and two more dropped out very early on. As shown in Fig. 1, that left 28 frontline health workers from all 4 regions of Inuit Nunangat actively participating in the course. There was an excellent spread of participants from the 4 Inuit regions, with greatest participation from the Inuvialuit Settlement region (4 participants from 6 communities, or a 67% participation rate) and Nunavut (17 participants from 26 communities, or 65%). Nunatsiavut had 3 participants from 6 communities (50%), and Nunavik had 4 participants from 14 communities (29%).

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There was a good balance of participants from small, medium and large communities something the Advisory Group had specifically requested. Some participants had previous training in tobacco reduction; others did not. The majority were CHRs. With one exception, all participants were Inuit/Inuvialuit (96%), and all but 2 were women (93%).

Dates The course ran from 1 March to 31 May 2010. On-going support was then provided to participants as needed after the official end of the course. Educational approach The programme used ‘‘asynchronous’’ distance education: participants worked on their own schedule and had one-on-one contact with the trainers at a time that suited them and their work schedules. (In ‘‘synchronous’’ learning, on the other hand, all students are present at the same time, for example, for a videoconference or conference call.) We used individual telephone calls, mail, e-mail and fax to communicate. E-mail access is unfortunately still very limited for many frontline health workers in Inuit Nunangat. Many share an office, and some have never been adequately trained in the use of computers. Telephone was therefore the communication method of choice, but it sometimes took several attempts as participants were often out in the community or assisting the nurse in the health centre when we called. This distance education course included elements of self-directed learning. We recognized that each person had unique past experiences and learning needs, so we wanted to offer a course that would:

. recognize their prior knowledge and experience; . involve them in identifying their own learning needs and planning how best to meet them directing and managing their own learning (with the trainers’ help); . support them with individual telephone calls (and e-mail where appropriate), and continue to provide follow-up support after the course ended if desired; . enable them to integrate their learning into their everyday work and help them to implement practical projects in their communities; and . build their capacities as health workers so that they could better help to improve the health of their communities.

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education reaches far Distance

Fig. 1. Twenty-eight participants participated from all regions of Inuit Nunangat; the trainers were based in Montreal.

A self-directed course like this places the learner not the trainer at the centre. And because each participant is different, a pre-packaged approach is much less effective than a self-directed approach. We have found over many years that this is the best way to work with adults as they continue to develop their knowledge, attitudes and skills for their jobs.


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Course options, learning materials and core competencies Participants selected their main area of interest from a ‘‘menu’’ of 6 course options. Each option required the study of different learning materials, and core competencies were specified for each option (see Fig. 2). Pre- and post-test self-assessments Once participants had chosen from the menu of 6 course options, they completed the relevant section of a pre-test self-assessment tool that contained a total of 24 core competencies (specified in Fig. 2) and 176 subcompetencies. (Every core competency was divided into between 2 and 4 detailed sub-competencies, for a total of 176.) Each participant only had to complete the relevant section of this self-assessment, depending on which course option he or she chose. The self-assessment form included 2 colour-coded columns, the first for the pre-test designed to assess learning needs and the second for the post-test. Participants used a four-point rating scale: 1 meant ‘‘I know nothing about this’’; 2 meant ‘‘I need to learn a lot about this’’; 3 meant ‘‘I only need to learn a bit about this’’; and

4 meant ‘‘I don’t need to learn any more about this’’. By rating themselves as mentioned earlier before and after the course, they were able to ‘‘measure their learning’’ on each detailed sub-competency.

Community projects Participants selected a community project to implement (choosing 1 of 12 options provided, or designing a unique project in consultation with their trainers), and used the course-related books, DVDs, flipcharts and telephone calls with trainers to prepare themselves for their projects. Examples of suggested projects were:

. Prepare a talk to give at the school about the health effects of tobacco use (what teaching methods and aids would you use?); . Learn about withdrawal symptoms and how to explain them to smokers; . Host a phone-in radio show about tobacco reduction; . Design your own project and negotiate with your trainer to do that instead of one of the suggested projects.

Fig. 2. Course options, learning materials and core competencies.

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Flexibility The duration of the course (between 2040 hours over 3 months) was flexible to take into account the differences in projects and seasonal activities across the regions. Other issues such as vacation or sick leave, competing study programs, shortages of clinic staff and the pattern of life in each community all had a bearing on the time needed for each participant to complete their course. Flexible learning opportunities are particularly important for Aboriginal learners (32,44,45). Studies were completed in on-duty time.

community. Each participant followed their own customized programme and had regular contact through telephone with the trainers. After the course had officially ended, the trainers offered follow-up support to participants to undertake activities to continue addressing tobacco reduction in their communities. To summarize, Fig. 3 shows a flowchart with the 6 main steps used in the course.

Communication and support during and after the course Personal contact with participants was through phone, e-mail and fax. The main incentive for remaining in this program was the personal support participants had from trainers and the new tobacco education resources they were trained to use and had available for their work in the

Course completion The criteria for course completion were: (a) participants completed regular phone calls with the trainers in which they showed progress on studying the learning materials provided; (b) completed the pre- and post-tests; and (c) completed an approved community project to the satisfaction of the trainers.

Results and discussion

Fig. 3. The 6-step course flowchart. Citation: Int J Circumpolar Health 2013, 72: 21078 - http://dx.doi.org/10.3402/ijch.v72i0.21078

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Of the 30 original participants, 27 (90%) completed the course. (If we exclude the 2 people who dropped out right at the outset, the completion rate is 27 out of 28, or 96%.)

Pre- and post-tests The mean score for pre-tests was 72% (range: 3898%). To help consolidate learning and fill in gaps, participants used the post-test tool with an open book. This necessarily produced a 100% score because, where needed, they were directed to the correct answer with page references to complete any incomplete or incorrect answers. While this obviously cannot qualify as a true post-test, the mean improvement over pre-test scores was 28% (range: 262%). Phone calls Calls lasted from 10 to 45 minutes each. These calls were essentially individualized telephone tutorials. More than 420 calls were made during the project. Community projects Participants completed some excellent community projects as part of the course. Examples include: (a) Offered individual counselling to colleagues at the clinic who wished to quit but kept relapsing; (b) Offered a support group for smokers who wished to quit; (c) Ran educational sessions in the school using the Smoking Sucks book and DVD (several participants chose this option, and some invited youth to co-facilitate sessions with them); (d) Launched a poster competition about the harmful effects of smoking; (e) Worked on own personal plan to quit smoking using the resources from the course and with encouragement from family.

Feedback from participants At the end of the course, when the trainers telephoned each participant to do the post-tests, they asked for feedback about various aspects of the course. Comments were typed as people spoke. (Note that efforts to reach the supervisors of course participants for their feedback were unsuccessful due to high staff turnover and annual and other leaves causing temporary replacements to be in charge when we tried to contact people.) Learning materials Participants commented that they appreciated the supplied learning materials for their accessibility, cultural appropriateness, Inuit content and Inuktitut syllabic translation. They mentioned that before the course they had had few if any new, appropriate materials for their community education work, or to give to clients.

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. It’s about time that we got some new resources for tobacco education. My old [resources] have been seen many times before so now with the new books, [people] will be interested. . I read the books and they are really good. I’ll use them every time now and they’ll really help the smokers I am working with . . . Now with Healing from Smoking and Helping Smokers Heal I will have the help that I didn’t have before. . I really like Healing from Smoking and particularly the illustrations they make it easy for people to understand and to want to learn more. My next step will be to facilitate a study group of the health workers at the clinic who are smokers [using the book] . . . . People who look into those books of yours [Smoking Sucks: Kick Butt!] are all wanting to have a copy for themselves, so I just gave them all out and now I need more. . I have 3 smokers at home even while I am a nonsmoker, so I get frustrated I don’t know how to talk to them. Now I feel more like trying again with help from Healing from Smoking and Smoking Sucks.

Telephone support As a result of the on-going support during the course, the trainers informed and inspired participants to keep trying to reduce tobacco use in their communities.

. Having an update like this course really helps to get me focused on tobacco again because there are so many other crises coming up. . This talk [phone conversation with trainer] is helping me to get my confidence again. I lost confidence in myself and felt guilty when I started smoking again. That was after 10 years of being a non-smoker. . I feel bad about doing nothing on tobacco for more than two years now, so I am pleased to get some help to start again.

Quitting smoking A key part of the philosophy of this course was that even current smokers can encourage others to quit or not to start smoking. We never ‘‘blamed or shamed’’ CHRs who were themselves smokers. Nevertheless, several participants used this opportunity to quit smoking.

. I quit smoking in April, shortly after the course started, and have not smoked since. A group of 8 women decided to quit to support me, and after several months, only one has relapsed.



. I surprised myself by quitting smoking on 10th March. I’d never tried to quit before. What helped was that I wanted to be able to help others. The patch was helpful. Before, I even used to get up in the middle of the night for a cig. Friday, 30 July 2010: I am still a non-smoker and am incredibly proud and surprised at myself for quitting . . . I am just so happy that I got the opportunity to do this course.

Follow-up support Follow-up support often made the difference between a trainee staying active in tobacco reduction and simply going back to the status quo before training, where this topic is neglected due to more immediately pressing health problems in the community. Examples of follow-up support that made a difference include one CHR who used what she had learned during the course to be a co-trainer in a Government of Nunavutsponsored Smoking Sucks workshop for Inuit youth from the Kitikmeot region, and to be a mentor to the youth who attended the workshop during their subsequent community projects. (The lead trainer on the Smoking Sucks workshop was one of the trainers from this distance education course.) She stated that in the period before her course began, she had stopped doing tobacco education because there was not much community support. However, the course and the follow-up engagement with the project team re-kindled her confidence and enthusiasm to work on tobacco reduction again. Another CHR was also a co-trainer in a Smoking Sucks workshop in the Kivalliq region of Nunavut. Her studies on the distance education course put her in a good position to be a co-trainer, also working together with one of her trainers from this distance education course. In 2 other communities, course participants were working on a 6-year community-based participatory research project called ‘Changing the culture of smoking’. Examples of projects they have worked on in that capacity include offering annual community-wide smoking cessation challenges, doing a smoke-free homes survey, running tobacco education sessions in the schools and organizing community events such as radio shows and community quizzes to raise awareness about tobacco use. In all cases, participants reported that their learning on the distance education course has been very helpful.

Conclusion The very high completion rate (90%) achieved for this course shows that there is a clear role for individualized distance education that is flexible, culturally affirming, and learner-supportive. Face-to-face workshops in Inuit regions are extremely difficult to organize due to vast

distances, high travel and accommodation costs and extreme weather which may prevent participants from attending. As long as adequate and on-going support is provided, we recommend this approach to others working in circumpolar regions. Competency-based self-directed distance education is not simply a cheap alternative to face-to-face training. Its real strength is that it goes much further, much ‘‘deeper’’ by consolidating ‘‘learning and doing’’ in the learner’s real-life work setting. The one-on-one approach accommodated varying levels of past experience and different learning needs and styles, while following up with and supporting each participant. With relevant resources and the opportunity to practise using them while receiving support from trainers, participants provided improved access to tobacco cessation and prevention services for their communities. The trainers felt that this intensive approach would have been better done with a smaller group: supervising 28 individualized programs was a real challenge, especially given the limited use of e-mail. Also, a multi-year approach would consolidate learning and improve outcomes in successive community interventions, allowing participants to build on knowledge and skills gained earlier, and take their tobacco reduction practice further. Inoculation against the epidemic of tobacco use cannot be accomplished with a single jab.

Acknowledgements The authors thank all the participants who worked with them on this course. Their dedication to learning and to tobacco reduction in their communities was inspiring. And the authors are grateful to Health Canada for financial support.

Conflict of interest and funding All authors confirm that they have no financial and personal relationships with other people or organizations that could potentially influence the results or interpretation of the information presented in this article.

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*Rob Collins Consultancy for Alternative Education 6 Sunny Acres Baie-D’Urfe´, QC Canada Tel: 514-457-4990 Email: [email protected]


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Associations of deliberate self-harm with loneliness, self-rated health and life satisfaction in adolescence: Northern Finland Birth Cohort 1986 Study Anna Reetta Ro¨nka¨1,2*, Anja Taanila2,3, Markku Koiranen2, Vappu Sunnari1 and Arja Rautio4 1

Women’s and Gender Studies, Faculty of Education, University of Oulu, Finland; 2Institute of Health Sciences, University of Oulu, Finland; 3Primary Health Care Unit, University Hospital of Oulu, Oulu, Finland; 4 Thule Institute, University of Oulu, Finland

Background. Deliberate self-harm (DSH) is an act with a non-fatal outcome in which an individual initiates a behavior, such as self-cutting or burning, with the intention of inflicting harm on his or her self. Interpersonal difficulties have been shown to be a risk factor for DSH, but the association between subjective experience of loneliness and DSH have rarely been examined. Objective. To examine the frequency of DSH or its ideation and loneliness among 16-year-olds to determine if associations exist between DSH and loneliness, loneliness-related factors, self-rated health and satisfaction with life. Design. The study population (n 7,014) was taken from Northern Finland Birth Cohort 1986 (N9,432). Cross-tabulations were used to describe the frequency of DSH by factors selected by gender. Logistic regression analysis was used to describe the association between DSH and loneliness and other selected factors. Results. Nearly 8.7% (n608) of adolescents reported DSH often/sometimes during the preceding 6 months, with girls (n 488, 13.4%) reporting DSH almost 4 times than that of boys (n 120, 3.6%). Nearly 3.2% of the adolescents (girls: n 149, 4.1%; boys: n72, 2.2%) expressed that the statement I feel lonely was very/ often true, and 26.4% (girls: n 1,265, 34.8%; boys: n585, 17.4%) expressed that the statement was somewhat/sometimes true. Logistic regression showed that those who reported to be very/often lonely (girls: odds ratio (OR) 4.1; boys: OR 3.2), somewhat/sometimes lonely (girls: OR 2.4; boys: OR 2.4) were dissatisfied with life (girls: OR 3.3; boys: OR 3.3), felt unliked (girls: OR 2.2; boys: OR 6.0) and had moderate self-rated health (girls: OR 2.0; boys: OR 1.7), were more likely to report DSH than those without these feelings. Conclusion. The results show that loneliness is associated with DSH, and that loneliness should be considered as a risk for individual health and well-being. Keywords: deliberate self-harm; loneliness; adolescents; gender; Northern Finland

uicide is one of the leading causes of death among adolescents in the Western world (1). In Finland, suicide rates of children and adolescents are among the highest in the world (2). Every year, more than 100 Finnish children or adolescents aged 1024 commit suicide (3). The suicide rates are higher among males, while adolescent females report more deliberate self-harm (DSH), suicide ideation and attempts (2,4). However, the suicide rate for adolescent girls in Finland has steadily increased over the last few years (2).

S

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In our study, we examine DSH and its association with loneliness and related factors, self-rated health and life satisfaction among Finnish adolescents. DSH is an act with a non-fatal outcome in which an individual initiates a behavior (such as self-cutting, burning, ingesting excess medicines/drugs, ingesting a non-ingestible substance/object, jumping from a height) with an intent to harm his or her self (5). DSH is common in adolescence; the reported mean lifetime prevalence of DSH is 13.2% (6) and prevalence during the preceding 12 months


Associations of deliberate self-harm with loneliness

ranges from 6 to 26% (4,6). Documented motives for DSH include wanting to get relief from distress, to escape from (difficult) situations and to show how desperate one is feeling; it is a cry for help (7). Unnoticed or untreated DSH may precede suicide (1). Risk factors for DSH, suicidal ideation and completed suicides are often similar and include depression (8,9), excessive alcohol and drug use (1), physical and sexual abuse (8) and interpersonal difficulties, such as having troubled or poor relationships with peers and family (1,5). Therefore, the social domain, including experiences of loneliness, seems to be closely related to DSH (10). However, very little research has been conducted on the associations between DSH and subjective experiences of loneliness. Loneliness is a subjective, cross-cultural experience and part of the human condition that negatively affects the overall well-being. It also carries a health risk (11). In our study, loneliness is regarded as a negative, involuntary experience, which is in line with the large body of research on loneliness (11). Adolescent loneliness has been related to many negative mental and physical health and wellbeing factors, such as depression, high social anxiety (11), low self-esteem (12), victimisation of bullying (13) and poor self-rated health (14). Among young adults, chronic feelings of loneliness have been associated with disturbances in sleep and higher blood pressure and cardiovascular functioning (15). Loneliness is very common in adolescence (age: between 12 and 22 years); 2050% of all adolescents experience some degree of loneliness (11,16). Few studies have examined the relationship of subjective experience of loneliness to DSH before (17). Furthermore, very few population-based cohort studies have examined DSH (9,18). Small sample sizes are typical of the Northern communities when examining suicidal behavior and, overall, many earlier studies of adolescent suicidal behavior have been conducted on psychiatric samples or on hospital admissions. These can result in research designs with low statistical power (19), and these kinds of data might distort or underestimate the prevalence of suicidal behavior, including DSH. Therefore, findings from non-clinical populations will be more representative of adolescents (6). Furthermore, cohort data have been used to examine experiences of loneliness among the adult and the elderly in Finland (20) and elsewhere (21), but the experiences of loneliness in adolescents have rarely been examined in large population-based cohort studies. Two different populationbased cohorts, 20 years apart, have been collected from Northern Finland, entitled Northern Finland Birth Cohort (NFBC) 1966 and NFBC 1986. One purpose of these cohorts is to follow societal changes and to examine the changes in the psychosocial well-being of the cohort members in the same area. These cohorts are the only

Finnish data, which have examined longitudinally and this rigorously the life path of individuals in Northern Finland, both physically and psychically. Our data offer a unique opportunity to understand the association between DSH and loneliness, and this study is the first to examine the theme of loneliness in the NFBC 1986 data. The rates for suicidal behavior are different for boys and girls (5), and different genders might experience different levels of loneliness (11). With our large and robust sample, we are able to compare the DSH behavior in relation to loneliness for girls and boys separately. Also, few studies have examined the association of DSH with self-rated health before, even though DSH is seen as a serious health issue (6). This study hypothesised that (a) DSH is associated with loneliness and related factors, poor self-rated health and satisfaction with life and (b) girls and boys differ in these associations. The aims of this study are to examine the frequencies of DSH and loneliness among adolescents in the Northern Finland Birth Cohort 1986 (NFBC 1986) and whether DSH is associated with selected loneliness and related factors and if there exist differences in those factors among girls and boys.

Materials and methods Population and procedure The sample is based on a general population-based study NFBC 1986, which was collected from the 2 northernmost provinces in Finland (Oulu and Lapland) comprising 9,432 live born infants (4,567 girls and 4,865 boys) whose expected date of birth fell between 1 July 1985 and 30 June 1986. They have been prospectively followed since the prenatal period with follow-ups at ages 78 years (19921994) and 1516 years (20012002). The next data collection for the cohort members is slated for 2013, when they would be 2728 years old. When cohort members were 1516 years old in 2001 2002, 9,340 of them were alive (99% of all), and the addresses of 9,215 were known. At that time, adolescents received a postal questionnaire concerning family structure, friends, school, health, living habits, hobbies and behavior (22). The study population consists of members of the NFBC 1986 who answered the question I feel lonely in the postal questionnaire in 20012002. Parents and adolescents who opposed to the use of their data (n209) were excluded from the analysis. The study population included 7, 014 participants (3,641 girls and 3,373 boys, mean age: 15.5). The ethical committee of Northern Ostrobothnia Hospital District reviewed this study. Written informed consent was obtained from the parents and the adolescents in the follow-up study in 20012002.


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Variables used in the analysis Dependent variable We derived the item 18 I harm or I would like to harm myself on purpose1 from the Youth Self-Report Scale (YSR) (23), which was part of the adolescents’ questionnaire. In this scale, the participants assessed whether each statement had been true for them during the preceding 6 months. The item was labelled as deliberate self-harm or ideation (DSH). The response alternatives for all YSR items were: 1, not true; 2, somewhat/sometimes true and 3, very true/often true. Those scoring 2 or 3 on item 18 were defined as having experienced DSH similar to the earlier study using the same scale (9). Explanatory factors Subjective experience of loneliness was measured by the single-item variable I feel lonely from YSR. The second YSR item was I feel that no one likes me and was recoded as Not being liked; No (response alternative 1) and Yes (2,3). We also chose the item Do you have a close friend with whom you can confidentially discuss your matters? The response alternatives being: 1, I have no close friends; 2, I have one; 3, I have two; and 4, I have several. These were recoded to number of close friends: one/more (response alternatives 24) and none (1). Satisfaction with life was queried as What is your opinion about your current life situation? Response alternatives were: 1, I cannot say; 2, Very dissatisfied; 3, Fairly dissatisfied; 4, Fairly satisfied and 5, Very satisfied. These were recoded as Satisfied (response alternatives 4,5), Cannot say (1) and Dissatisfied (2,3). Self-rated health was assessed as How would you describe your health? The response alternatives were: 1, Very poor; 2, Poor; 3, Moderate; 4, Good and 5, Very good. These were recoded as Very good/good (response alternatives 4,5), Moderate (3) and Poor (1,2). Self-reported health status is a common variable for measuring the self-concept of health (14). Statistical analyses We used cross-tabulations to describe the frequency of the DSH by dimensions of loneliness, loneliness-related factors, self-rated health and satisfaction with life by gender. We employed logistic regression analyses to describe the association of DSH with all 5 selected explanatory factors with DSH. Wald’s test was used to test the statistical significance of the OR where P values B0.05 were considered as statistically significant. IBM SPSS Statistics 19 was used to perform all statistical analyses. 1 This is the wording of the item as stated in Finnish. The English translation in the questionnaire was: ‘I deliberately try to hurt or kill myself’. In the Finnish version, the question was changed by its wording, since it was thought that if the statement has the word suicide in it, it might give adolescents ideas of suicide.

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Results A total of 608 adolescents (8.7%) reported DSH or ideation. More girls (n 488, 13.4%) than boys (n 120, 3.6%) reported DSH during the 6 months preceding the survey. In total, 221 adolescents (3.2%) of the respondents expressed that the statement I feel lonely was very true/often true; thus, they were very lonely. Girls reported it more frequently in comparison to boys (girls: n 149, 4.1%; boys: n 72, 2.2%). In total, 1850 respondents (26.4%) answered that the statement was somewhat/ sometimes true; thus, they were experiencing some levels of loneliness and again girls reported loneliness more often than boys (girls: n1,265, 34.8%; boys: n 585, 17.4%). Boys reported having fewer close friends than girls and there were more girls who felt that nobody liked them. There were no differences in self-reported health among boys and girls; most of them reported having very good or good health. Most adolescents were satisfied with their lives (see Table I). Among adolescents who reported DSH, 40.9% of girls and 18.1% of boys were very/often lonely and 22.0% of girls and 9.4% of boys were somewhat/sometimes lonely. Of those who reported DSH, 18.0% of girls and 5.3% of boys did not have any close friends, 24.7% of girls and 13.7% of boys felt that nobody liked them, 30.4% of girls and 12.5% of boys reported having poor health and 40.5% of girls and 15.4% of boys were dissatisfied with their lives. Logistic regression was performed separately for girls and boys to assess the association of DSH with selected explanatory factors (see Table I). When controlling for all of the 5 variables in the model, the factors associated with having experienced DSH were feeling very/often lonely or somewhat/sometimes lonely (girls: OR 4.1 and 2.4, respectively; boys: OR 3.2 and 2.4, respectively), being dissatisfied with life (girls: OR 3.3; boys: OR 3.3), being unable to tell whether they were satisfied or not with their lives (only girls: OR 2.6), feeling of not being liked (girls: OR 2.2; boys: OR 6.0) and moderate self-rated health (girls: OR 2.0; boys: OR 1.7).

Discussion We studied the DSH or its ideation, feelings of loneliness, loneliness-related factors, self-rated health and satisfaction with life among of 16-year-old Finnish adolescents. The prevalence of DSH was 8.7% during the preceding 6 months, which was higher than prevalence found in reports from Australia and England (4,5). Very few earlier studies have examined DSH in Northern circumpolar areas. A Norwegian study, which used the same measurement as in this study, reported a prevalence of 12.5% among 487 adolescents aged 1316 years. (9). In a Swedish longitudinal study, a 9-item Deliberate SelfHarm Inventory was employed to examine DSH prevalence among adolescents, and as many as 41.6% of the



Table I. Distribution of subjects according to loneliness, lonelinessrelated factors and self-rated health, prevalence of deliberate self-harm (DSH) during the past 6 months and logistic regression of DSH Girls

Boys

Reported DSH Explanatory factor

No. of subjects

N

Reported Adjusteda

Unadjusted %

OR

95% CI

OR

95% CI

DSH

Adjusteda

Unadjusted

No. of subjects

N

%

1.9

OR

95% CI

OR

95% CI

Feeling lonely Never (ref.)

2,223

149

6.7

2,706

52

Somewhat/sometimes

1,265

278

22.0

3.9

(3.14.8)

2.4

(1.93.1)

585

55

9.4

5.2

(3.87.8)

2.4

(1.53.9)

149

61

40.9

9.6

(6.613.9)

4.1

(2.76.3)

72

13

18.1

11.2

(5.821.7)

3.2

(1.47.3)

3,503 122

465 22

13.3 18.0

1.4

(0.82.3)

0.5

(0.30.9)

2,938 360

98 19

3.3 5.3

1.6

(0.92.6)

0.6

(0.31.1)

No (ref.)

2,320

167

7.2

2,781

42

1.5

Yes

1,286

317

24.7

4.2

(3.45.1)

2.2

(1.82.9)

553

76

13.7

10.3

(7.015.3)

6.0

(3.89.5)

2,994

312

10.4

2,862

79

2.8

590

162

27.5

3.2

(2.64.0)

2.0

(1.62.6)

458

37

8.1

3.0

(2.04.6)

1.7

(1.12.7)

46

14

30.4

3.7

(1.97.1)

1.7

(0.83.5)

32

4

12.5

5.0

(1.714.6)

1.4

(0.45.0)

2.7

Very/often Number of close friends One/more (ref.) None Not being liked

Self-rated health Very good/good (ref.) Poor/very poor Satisfaction with life Satisfied (ref.)

a

3,234

349

10.8

2,988

80

Cannot say

167

52

31.1

3.7

(2.65.2)

2.6

(1.83.8)

133

12

9.0

3.6

(1.96.7)

1.8

(0.93.8)

Dissatisfied

210

85

40.5

5.6

(4.17.5)

3.3

(2.44.7)

182

28

15.4

6.6

(4.110.4)

3.3

(1.95.7)

Adjusted for all factors in the table.

165


Moderate


participants reported on the first measuring point that they had harmed themselves at least once in their lifetime and repeated self-harm (at least 5 instances) was reported by 18.3% of the adolescents (24). The large differences in the prevalence rates are likely to be due to the different methods, sample sizes and questionnaires used. The prevalence for DSH has been noted to be significantly higher for studies using anonymous methods, such as in this study, in comparison to non-anonymous methods (6). More generally, suicidal behavior is a severe public health concern in the Northern populations (25). Suicide rates are among the largest in the world, and suicides are one of the leading causes of death among youth (26), especially among indigenous young men (9). Girls reported DSH clearly more than boys (13.4% vs. 3.6%, respectively), similar to earlier reports (2,4,9). The 6month prevalence of DSH was found to be low (2.2%) among adolescent Finnish boys by using the same measurement (18). The prevalence of loneliness was 3.2%, and this result is in accordance with an earlier survey-based study conducted in Finland, which also used a single-item variable to assess loneliness and found that 3.6% of the youngest age group (age: 1829 years) felt lonely (27). Girls reported loneliness more often than boys. This finding is similar to the findings of other Finnish studies (16,28) but contrary to those published in some other countries, such as Canada or UK (29,30). However, these studies are not directly comparable to ours because of the differences in the measurement of loneliness. There was a significant association between DSH and loneliness among girls and boys. However, similar to other studies, an association between the number of close friends and DSH was not found (31). One explanation for the association between DSH and loneliness and the higher prevalence of DSH among girls and the higher prevalence of suicide among boys can be found from the varied and changing social relations during childhood and adolescence. Even though gendered patterns in social relations are changing (32), there seems to be a tendency wherein from early on girls are still taught to be kind and friendly to other people, to avoid conflicts (33) and to be caring, more so than boys. This can be interpreted girls to maintain the behavior of girls to think, worry and invest in social relations more than boys (32). Same-sex friendships among girls are generally considered more emotionally expressive and intimate than boys; girls spend time in smaller groups, while friendship among boys are considered more activity-oriented and consist of larger groups (32,34). Boys are often encouraged to be ‘‘tough’’, self-expressive and more independent than girls. The spectrum of allowed emotions for boys might be stricter than for girls; therefore, it might not be as socially acceptable for them, as it is to girls, to express different emotions (35). Therefore, boys might not report different

166

emotions or feelings as often in surveys or in general, as girls, and emotional and social difficulties might cause more emotional distress among boys. Loneliness can be very distressing for both girls and boys (11), but girls may have evolved better coping strategies to deal with emotional distress than boys. According to Gilligan and Machoian (36), DSH can be seen as a form of communication. Some girls may learn that when they threaten or actually harm themselves, their distress is heard (3,36). The suicidal and DSH behavior of girls includes signs of hope related to their social relationships; therefore, they turn to DSH behavior rather than actually committing suicide (36). Boys might notice the difficult emotions at a later stage, when the situation is already hopeless, and in serious cases, instead of turning to self-harming behavior, they turn to more violent methods (6); boys commit suicide much more often than girls. Furthermore, feelings of not being liked were significantly associated with DSH in both girls and boys. The OR was higher among boys than girls, suggesting that it is important to notice that adolescent girls and boys need trustworthy and supportive people around them. Without this, they have a higher risk of DSH. After adjusting for other factors in the regression model, DSH was significantly associated with moderate self-rated health among girls and boys, but not with poor health, which may result from intermediating effect of life satisfaction between poor health and DSH. However, this could be explained by the small number of subjects answering that their health was poor or very poor. DSH was clearly associated with dissatisfaction with life for girls and boys; obviously, those involved in DSH were not necessarily satisfied with their lives, and the motives for DSH may be to express their desperation (7). Finally, the experiences of loneliness and DSH can be context-related (37,38). The members of NFBC 1986 experienced a severe economic recession in Finland at the beginning of the 1990s that involved a reduction in state funding for health, social and educational services. The economy revived in the mid-1990s, but recession in public sector services continued (39). In Particular, in northern Finland, the issues of urbanisation and ‘‘death’’ of small villages, long distances and other social and economic problems, such as the poor availability of educational facilities and job opportunities (40), still exist. As an ongoing problem, they might contribute to growing marginalisation, loneliness, malaise and possibly to DSH and suicides among northern Finnish adolescents, and other Northern communities might face similar challenges. The strength of this study is the large general population birth cohort and a sample size that consists of more than 7,000 adolescents. The main limitations of the study are that the motives behind the DSH acts or the methods used for harming oneself were not researched, and the wording of the YSR item was changed. Therefore, the



results are not exactly comparable to other studies that reported different methods behind the DSH behavior or used the YSR scale. Furthermore, cross-sectional study design prevents us from claiming the causality of the observed associations.

Conclusion An association between DSH and experiences of loneliness were found. Loneliness and DSH should be viewed as serious social and health problems, since they have many negative consequences for an individual’s wellbeing and, in some cases, may lead to suicide. Parents might be unaware of their children’s DSH behavior (9). Identifying the lonely adolescent might be difficult due to the subjective nature of the experience. Health providers, parents and teachers should gain more knowledge about DSH and related factors, such as loneliness, and be updated on measures and tools for identifying the adolescent with these behaviors (41) in order to help them. Furthermore, the adolescents themselves should be encouraged to seek help (1), and more resources are required for student counselling. A whole-school approach, including the parents, aimed at enhancing emotional and social well-being could be helpful for changing the ethos and culture of the school. Belonging, nonviolence, awareness, openness and confidence in dealing with emotions and sensitive issues should be emphasised (8) in schools and at home. Children and adolescents should be taught emotional intelligence and empathy, which could help them discuss their emotions and feelings more openly without the fear of social stigma in a safe environment. Finally, DSH is common among adolescent girls. Suicide rates among girls are increasing, yet the malaise and suicidal behavior of girls has been underexamined. Future research using longitudinal and mixed methods research design should be conducted to gauge the possible stability and causality of DSH experiences and their relationship to loneliness and gender more thoroughly.

Acknowledgements The authors thank the blind peer reviewers for their valuable comments towards improving this article. Also, they thank Women’s and Gender studies and the Institute of Health Sciences Research Groups, University of Oulu, for their valuable comments. Furthermore, they thank the Mannerheim League of Child Welfare, the Alma and K.A. Snellman Foundation, Otto A. Malm Foundation, Women’s and Gender Studies of University of Oulu in the Faculty of Education, Thule Research Program and the Academy of Finland for funding this study.


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An examination of the social determinants of health as factors related to health, healing and prevention of foetal alcohol spectrum disorder in a northern context the brightening our home fires project, Northwest Territories, Canada Dorothy Badry1,2* and Aileen Wight Felske2,3 1

Faculty of Social Work, University of Calgary, Calgary, AB, Canada; 2Canada FASD Research Network Action Team on Women’s Health Member, Yellowknife, NT, Canada; 3Mount Royal University, Calgary, AB, Canada

Objective. The Brightening Our Home Fires (BOHF) project was conceptualized as an exploratory project to examine the issue of the prevention of foetal alcohol spectrum disorder (FASD) from a women’s health perspective in the Northwest Territories (NT). While dominant discourse suggests that FASD is preventable by abstention from alcohol during pregnancy, a broader perspective would indicate that alcohol and pregnancy is a far more complex issue, that is, bound in location, economics, social and cultural views of health. This project was prevention focused and a social determinant of health (SDH) perspective informed this research. Methods. The BOHF project was a qualitative research project using a participatory action research framework to examine women’s health and healing in the north. The methodology utilized was Photovoice. Women were provided training in digital photography and given cameras to use and keep. The primary research question utilized was: What does health and healing look like for you in your community? Women described their photos, individually or in groups around this central topic. This research was FASD informed, and women participants were aware this was an FASD prevention funded project whose approach focused on a broader context of health and lived experience. Results. This project drew 30 participants from: Yellowknife, Lutsel ‘ke, Behchoko¨ and Ulukhaktok. These four different communities across the NT represented Dene and Inuit culture. The qualitative data analysis offered themes of importance to women’s health in the north including: land and tradition; housing; poverty; food; family; health, mental health and trauma, and travel. Photovoice provides a non-threatening way to engage in dialogue on complex health and social issues. Keywords: foetal alcohol spectrum disorder; prevention; social determinants of health; Northwest Territories; women’s health; qualitative research; alcohol; northern health

he purpose of the Brightening Our Home Fires (BOHF) research was to engage with women in their home communities in northern Canada in relation to their beliefs and attitudes towards healthy living. It is recognized that individual and community experiences amongst women are critical to understanding new social perspectives of health determinants in northern Canada. While this research was positioned as an exploratory fetal alcohol spectrum disorder (FASD) prevention project, it was clear that the issue of FASD

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can be constructed as a product of many other factors that lead to women using alcohol to self-medicate against social and health problems. FASD has been broadly defined as a disabling condition that has multiple presentations including a primary lifelong organic brain injury caused by prenatal alcohol exposure. Alcohol consumption is commonly known as a means by which women buffer their own pain and trauma (1) and is a public health issue. Photovoice, a qualitative methodology, offered a way to gently engage with women on issues


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Dorothy Badry and Aileen Wight Felske

that were important within their lives and specifically in relation to health (Fig. 1).

BOHF as an FASD prevention project provided a window to at least raise the topic and some discussion amongst participants and research team members.

Objectives of the research A brief review of relevant literature (a) To identify voices of women in their home community through Photovoice work. (b) To understand factors that northern women see as contributing to their health and healing in their own community. (c) To understand what is unique to each community specifically for women in understanding health and healing and to identify factors, that may be protective and can potentially, contribute to FASD prevention grounded in a women’s health framework. The BOHF project represents the voices of women in the NT and their health concerns with a background focus on FASD prevention. The decision to engage in this research was driven by a need identified in the Northwest Territories (NT) from members belonging to the Canada FASD Research Network Action Team (NAT) on Women’s Social Determinants of Health. This project received ethics approval from the Conjoint Faculties Research Ethics Board of the University of Calgary and the Aurora Research Institute in the NT. The effectiveness of available FASD prevention information, generally perceived as stigmatizing by pregnant women was not viewed as effective, while the need to explore prevention existed. In terms of context, going into a remote community and simply opening discussions about FASD prevention was not considered to be an approach that would be successful by NAT members located in northern communities. With this in mind, the primary research question that emerged as guiding this project was: What does health and healing look like for you in your community? This question encouraged participation as it was considered relevant and non-threatening, and did not directly ask about alcohol use and pregnancy. However, signing informed consents and identifying

Fig. 1. A reunion at the Kugluktuk Airport with a project participant and a relative. Photo credit: Dorothy Badry.

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As this project was housed in a northern context, literature related to the SDH and implications for women’s health were reviewed. The BOHF research was reflective of a gendered position in terms of understanding women’s health as influenced by context, place and experiences of northern women. Benoit and Shumka (2) consider the roles of sex and gender in relation to the health of girls and women in light of the power these constructs hold in determining health outcomes. Of particular relevance to the BOHF project is the model proposed by Benoit and Shumka (2) that considers ‘‘sex and gender on equal footing with other fundamental determinants, including race, ethnicity . . . geographical location and age’’ (p. 10). In remote communities, girl’s and women’s health, practices and beliefs are intricately interwoven across generations and culture. Health disadvantages exist in the north with geography acting as a critical factor in opportunities to accessing health supports.

Social determinants of health Canada views health, as not just a state, but also a ‘‘resource for everyday life’’ (3, p. 9). Population research indicates that the key factors which influence health are: income and social status; social support networks; education; employment/ working conditions; social environments; physical environments; personal health practices and coping skills; healthy child development; biology and genetic endowment; health services; gender; and culture. Health of populations can be examined by age, gender, ethnicity or region. Such a focus reveals that health inequities are experienced by Canadians in certain areas of Canada and by certain groups including the north. As a concept, SDH have recently been readopted (4) with both a preventative (problem) and treatment focus.

Social determinants of health in the north An early case study by Hildes, Whaley, Whaley, Irving (5), a team of medical researchers on behalf of the Arctic

Fig. 2. A camera case made overnight by a project participant in Ulukhaktok. Photo credit: Dorothy Badry.


An examination of the social determinants of health

Fig. 3. Brightening our home fires image panorama.

Health Research Centres, studied the physiological response to cold in Old Crow, Yukon (Vuntut Guichen), as well as the state of health and well-being of individual community members. An overwhelming number of people in this small northern community were in good health and experiencing positive social well-being. Fifty years later, after the introduction of residential schooling and alcohol to northern life, a different picture emerges. Parlee, O’Neil and Lutsel ‘Ke Dene First Nation (6) examined the meaning of health within the context of Canada’s first diamond mine located in the territory of this community. This study examined health through questions such as; ‘‘What is a healthy community? What is it about the Dene way of life, that is, so important?’’ (p. 118). A key finding suggested that ‘‘many community members perceive that people were healthier when they were living on the land’’ (6, p. 116). Loppie, Wien (7) documented the health inequalities of Aboriginal people’s lives in Canada and proposed a model of organizing the SDH, as distal (e.g. historic, political, social and economic contexts); intermediate (e.g. community infrastructure, resources, systems and capacities); and proximal (e.g. health behaviors, physical and social environment).

The complexity of SDH attracts researchers in the areas of social and community engagement, as it potentially offers a new avenue of solutions. Cameron (8) identified emerging health trends in Inuit communities including rising rates of diabetes and nutritional concerns as less traditional diets are followed. Other concerns include increasing sexually transmitted infections, youth suicide and issues related to intergenerational trauma. Cameron offers a contemporary review of the SDH and indicates that health is largely linked to socio-economic factors including: acculturation, productivity, income distribution, housing, education, food security, healthcare services, social safety nets, the quality of early life, addictions and the environment. What is the bridge that links FASD as part of the picture of health?

An FASD lens FASD prevention is best addressed in First Nations and Inuit communities from a cultural, historic, political and social context and often takes different forms from mainstream approaches (9) for reasons of geography and access to health-related resources. Poole (10)


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indicated that women’s alcohol use is not just about alcohol. It is also about stress, context, isolation, general health, age, genetics, resilience, cultural discrimination, exposure to violence, abuse, access to prenatal care, grief and loss, social policy and poverty. Approaching FASD from a cultural lens, that is, respectful of history while moving a women’s health agenda forward, positions FASD as a health problem requiring supports for atrisk families with a goal of child and family health wherever families reside in Canada.

Methodology Photovoice is a participatory action research approach to working in communities on health and social issues and position participants as co-researchers of the study. Digital cameras were provided to women participants and team members offered a community workshop on using the cameras and taking pictures. Once photos were taken, a meeting took place and for most women, their photos were discussed and captions developed individually rather than in a group setting. In a community a translator was needed. Atlas Ti, a qualitative software programme was utilized to consolidate, review and code text to support developing a portrait and themes in response to the question: What does health and healing look like for you in your community? (Fig. 2)

Results Through the BOHF research and based on the findings from a depth analysis of key themes, text and images, the SDH were re-examined with a perspective contextually grounded in northern Canada. The SDH provided an anchor and framework to consider and examine the photovoice findings of this project on health, healing and FASD prevention for women in northern Canada.

Key themes emerging from the brightening our home fires project Key themes that emerged from the project in relation to an SDH framework included: land and tradition; housing, poverty, food, family, health, mental health and trauma, and travel. An additional discussion with a participant provided insight into how travel in the north potentially affects health needs. Within the limitations of this paper, we briefly present captions and images from these findings through the voices of women participants. Women experiencing homelessness in Yellowknife shared images that were quite divergent from women living in a community. This panorama of photographs serves to illustrate how images portray places and different experiences (Fig. 3). In relation to the key themes, a few illustrative captions from the panorama of photographs are shared below in the order that the images are presented.

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Theme: land and tradition Image 1: The tree. The tree clears the air and it’s healthy. It’s part of nature, part of the world. We need the tree. It makes me happy because it looks nice there. It makes it nice for the city. It makes me feel sad for the tree being in the cold weather. It is challenging to be in the cold. I’ve been out in the cold and it’s cold, very cold. Images 2 & 3: Our land. Looking out my front window our country food Arctic char, berries, a round bannock type bread and soups. Image 4: My work my handicrafts. Part of my therapy is through my handicrafts, which are very relaxing in creating the colors and the choice of colors the colors I choose reflect my healing and how far I have come. I have a need to see the mistakes I make sometimes in my own life and reflect on how beautiful life on my own life can be through my creations. Sometimes it ’s so easy to go back and see the mistakes in life and as I do my creations through my crafts it brings me right back up. I do not stay too long in my own negative world I used to be in, because it was back in my lifetime, the time of darkness and pain. As I do my handicrafts it helps me to relax and take pride in my work and be real in my own healing journey . . . Theme: housing/poverty Image 5: Plastic bin and mattresses at the Centre for Northern Families in Yellowknife. I’d like to find a better place. There is no room too close together, have to fold mats, women shower and go early before fights start, clothes, more luggage, have to wipe clean mats some women leave and don’t help. Clothes; dirty and clean all mixed up, no room. I used to have a place. Theme: food Image 6: Inuit Boarding Home (Larga House) near downtown Yellowknife. This clinic is for pregnant ladies and other patients. They have Inuuk food; fish, char caribou, musk ox, and polar bear. When you are from out of town you are allowed to live there when you are a patient. It’s important for Inuit to have that clinic. I was in the old clinic for medical help. I got bedding, a room, I had food there. That helped. Image 7: Arctic char frozen in a porch at the Kayuktuk Centre, Ulukhaktok, NT. Community Spirit of Sharing. This fresh catch of Arctic Char was harvested by two local fisherman hired by the local hunters & trappers organization. The fish is distributed amongst the local community members. Sharing of country or native foods is part of our Inuvialuit culture, especially to elders and single women with children. Theme: health, mental health and trauma Image 8: Medicine Rock. Medicine rock. Keep it heated on the stove. Many uses. Warmth in a pack when out on the land; calming, relaxing, pain relief. It is precious to me. Medicine Rock warming my hands.


An examination of the social determinants of health

Image 9: Back alley. We go main street meet friends outside the bar who will give me a shot of drinks. Sometimes [there’s] nothing to do back to the same old place. People are jealous and put me down. Say things like ‘‘she’s too good’’ or making other friends not accepted. Sometimes the women fight and call each other down, even sober. Image 10: Table and computer at the Centre for Northern Families, Yellowknife, NT. This is the first thing I’m starting on just trying to learn one day at a time working on those things like learning computers instead of being out there and enjoying myself (being out there and having a party and not trying to think twice about going the right way in life). This life doing simple things to keep my mind away from other things I have done in my life. If I just stay forward hopefully there is something out there that will keep my mind off drinking and find a simple thing to keep me doing other things I want to do in my life. May the good spirit always be with us.

Theme: travel This quote emerged from a discussion with a woman participant who also acted as a translator in a remote community and highlighted the need to consider travel as a social determinant of health in a northern context. Many times people’s health deteriorates as they wait for appointments. Even for alcohol treatment issues that are acute, the need must be expressed, you ask for help and wait for the next approval from the headquarters of the regional office, make an appointment, find out if beds are available and have to wait for an available bed . . . [and] the process takes a long period of time. Treatment for youth at risk is also a long waiting time and experiences of chaos and abuse occurring within families and overwhelming family units while trying to take care of the person, while trying to maintain some routine in the family. The worker in the community comes up against unseen walls of red tape . . . in trying to find the space and the right treatment centre not just availability but who will pay.

This quote illustrates the need to consider the role of travel as fundamental in relation to determining health. We believe travel should be considered as a new social determinant of health in northern, remote and isolated communities in Canada.

Conclusions The BOHF research project was initiated by members of the Canada FASD Research Network Action Team on Women’s Social Determinants of Health located in the NT. It offered additional resources related to consultation, professional research expertise drawn from the NAT membership and provided on-going support for the project. While the BOHF project was exploratory in relation to FASD prevention, it was evident that a focus

on women’s health as contextualized in place and environment such as communities in northern Canada is crucial to develop awareness and programmes. The construct of ‘‘place-based research’’ put forward by Parlee et al. (6, p. 129) is important as ‘‘place’’ has clearly distinct meanings between disenfranchised, homeless women in a more urban setting in Yellowknife than other women participants living in their home communities. FASD prevention work must be community specific and wrapped in a healthy families envelope from a policy perspective. Focused prevention work must begin earlier than first contacts with the medical system regarding pregnancy and must be linked with the dominant views of health in particular communities, mindful of tradition, culture and the high value placed on connections to children, family and community. Women who are disenfranchised from their communities through homelessness face many challenges and should have access to similar resources such as local food and traditional activities. Experiences on the land and related to the land were identified as particularly important for women in the north. A need exists to highlight the importance of access to local foods (high-protein meat) during pregnancy, and an avoidance of ‘‘southern risks’’ such as alcohol and processed foods high in glucose and carbohydrates could be highlighted as a prevention activity. A focus on overall general health for women supports FASD prevention. Programmes and policies could be expanded that support low stress, land and cultural focused activities that are seen as important during a pregnancy. The images and text generated in the BOHF project offer a glimpse into social concerns of the north including homelessness, poverty, health-related services, historical trauma, geographical barriers, housing and challenges in social safety nets in areas such as food security. The other construct emerging from this research is a portrait of connectedness to the land, traditional activities, culture, country foods, as well as strengths and resiliency grounded in community and place. We believe that photovoice offers a convincing research model to assist and support the involvement of northern women in Canada in important health discussions respectful of identity, place and culture. A pathway to FASD prevention and awareness programmes in northern, remote and isolated communities in Canada must be location-specific and designed and driven by community members themselves. In its delivery, FASD prevention programmes in the north are best served by local supports through constructing an agenda or programme of FASD awareness and prevention grounded in culture and a northern identity.

Acknowledgements The authors thank the women participants from the communities of Yellowknife, Behchoko, Lutsel ‘Ke and Ulukhaktok for providing the images taken in 2012 for the BOHF project.


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Conflict of interest and funding The First Nations and Inuit Health Branch (FNIHB) funded this project from 2010 to 2012.

References 1. Grant T, Ernst C, Pagalilauan G, Streissguth A. Post program follow-up effects of paraprofessional intervention with highrisk women who abused alcohol and drugs during pregnancy. J Community Psychol. 2003;31:21122. 2. Benoit C, Shumka L. Gendering the health determinants framework: why girls and women’s health matters: women’s health research network; 2009 [cited 2013 Mar 20]. Available from: www.whrn.ca. 3. Northwest Territories. 2011 Health status report. [cited 2012 Jun 15]. Available from: http://www.hlthss.gov.nt.ca/pdf/ reports/health_care_system/2011/english/nwt_health_status._ report.pdf. 4. Health Canada. 1986 Ottawa charter for health. [cited 2012 Jun 1]. Available from: http://www.phac-aspc.gc.ca/ph-sp/docs/ charter-chartre/index-eng.php. 5. Hildes JA, Whaley R, Whaley H, Irving L. Old crow a healthy Indian community. Can Med Assoc J. 1959;81:83741. 6. Parlee B, O’ Neil J, Lutsel ‘Ke Dene First Nation. The Dene way of life: perspectives on health from Canada’s north. J Can Stud. 2007;41:112133. 7. Loppie RC, Wien F. 2009 report (Canada) Health inequalities and social determinants of aboriginal peoples’ health

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[cited 2012 Nov 12]. Available from: http://www.nccah-ccnsa. ca/docs/social%20determinates/NCCAH-loppie-Wien_report. pdf. 8. Cameron E. State of the knowledge Inuit public health, 2011. [cited 2012 Nov 12]. Available from: http://www.nccah-ccnsa. ca/docs/setting%20the%20context/1739_InuitPubHealth_EN_ web.pdf. 9. Salmon A, Clarren SK. Developing effective, culturally appropriate avenues to FASD diagnosis and prevention in Northern Canada. Int J Circumpolar Health. 2011 [cited 2012 Nov 12]. Available from: http://www.circumpolarhealth journal.net. 10. Poole, N. (2003). Mother and child reunion: preventing fetal alcohol spectrum disorder by promoting women’s health. Vancouver, BC: BCCEWH [cited 2012 Nov 12]. *Dorothy Badry Faculty of Social Work University of Calgary 2500 University Drive NW Calgary, Alberta T2N 1N4 Canada Email: [email protected]


BEHAVIORAL HEALTH

Smoking-related knowledge, attitudes, and behaviors among Alaska Native people: a population-based study Kristen Rohde1*, Myde Boles1, Chris J. Bushore1, Barbara A. Pizacani1, Julie E. Maher1 and Erin Peterson2 1

Program Design and Evaluation Services, Multnomah County Health Department and Oregon Public Health Division, Portland, OR, USA; 2Tobacco Prevention and Control Program, Alaska State Department of Health and Social Services, Anchorage, AK, USA

Background. Several studies have shown that Alaska Native people have higher smoking prevalence than nonNatives. However, no population-based studies have explored whether smoking-related knowledge, attitudes, and behaviors also differ among Alaska Native people and non-Natives. Objective. We compared current smoking prevalence and smoking-related knowledge, attitudes, and behavior of Alaska Native adults living in the state of Alaska with non-Natives. Methods. We used Alaska Behavioral Risk Factor Surveillance System data for 1996 to 2010 to compare smoking prevalence, consumption, and cessation- and second-hand smoke-related knowledge, attitudes, and behaviors among self-identified Alaska Native people and non-Natives. Results. Current smoking prevalence was 41% (95% CI: 37.9%44.4%) among Alaska Native people compared with 17.1% (95% CI: 15.9%18.4%) among non-Natives. Among current every day smokers, Alaska Natives were much more likely to smoke less than 10 cigarettes per day (OR 5.0, 95% CI: 2.69.6) than non-Natives. Compared with non-Native smokers, Alaska Native smokers were as likely to have made a past year quit attempt (OR 1.4, 95% CI: 0.92.1), but the attempt was less likely to be successful (OR 0.5, 95% CI: 0.20.9). Among current smokers, Alaska Natives were more likely to believe second-hand smoke (SHS) was very harmful (OR 4.5, 95% CI: 2.87.2), to believe that smoking should not be allowed in indoor work areas (OR 1.9, 95% CI: 1.13.1) or in restaurants (OR 4.2, 95% CI: 2.56.9), to have a home smoking ban (OR 2.5, 95% CI: 1.63.9), and to have no home exposure to SHS in the past 30 days (OR 2.3, 95% CI: 1.53.6) than non-Natives. Conclusion. Although a disparity in current smoking exists, Alaska Native people have smoking-related knowledge, attitudes, and behaviors that are encouraging for reducing the burden of smoking in this population. Programs should support efforts to promote cessation, prevent relapse, and establish smoke-free environments. Keywords: smoking; smoking cessation; Alaska Native people; disparities; indigenous populations

igarette smoking is common among Alaska Native people: 41% of Alaska Native adults living in the state of Alaska are current smokers (1), compared with 19% in the US adult population (2). Studies of the disparity in adult smoking among racial and ethnic groups living in the United States typically combine Alaska Native and American Indian populations together (3,4). To our knowledge, only one published study has examined population-based data on the prevalence of tobacco use among all Alaska Native adults living in the state of Alaska (5). Other studies of tobacco use among Alaska Native people have been focused on a subset of the Alaska Native population, such as pregnant

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women (6,7), youth (8), those with children in the home (9), or those in specific areas of the state (1012). The primary purpose of this study is to provide current population-based estimates of smoking prevalence among Alaska Native people living in Alaska and augment these data with a broad array of new information on smoking-related knowledge, attitudes, and behaviors. We are unaware of any population-based studies that have assessed this type of information in the statewide Alaska Native population. It is important to assess knowledge, attitudes, and behaviors surrounding smoking in order to develop effective, culturally tailored interventions that are acceptable to Alaska Native people.


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Method Population Alaska Native people refers to the original inhabitants of the land that is now the state of Alaska. There are more than 120,000 Alaska Native people who currently live in Alaska, and they comprise about 17% of the state’s 720,000 residents. Data source We report on data from the Alaska Behavioral Risk Factor Surveillance System (BRFSS) from 1996 to 2010. The Alaska BRFSS is part of the national BRFSS, and it is a population-based, random-digit-dialed, crosssectional survey stratified on geographic region. Eligible participants are non-institutionalized (i.e. nursing homes, dormitories), aged 18 years or over, who speak English (13). In 19962010, the Council of American Survey Research Organizations (CASRO) response rate ranged from 47.7% (year 2000) to 67.5% (year 2005). Alaska presently conducts 2 BRFSS surveys: the standard BRFSS and a supplemental Alaska BRFSS, which contains many tobacco questions adapted from the Center for Disease Control and Prevention’s (CDC’s) Adult Tobacco Survey. Both surveys are conducted throughout the year, and separate samples are drawn using the same methodology. At present, approximately 210 Alaska adults are interviewed each month for the standard BRFSS to reach an annual sample size of 2,500; the same number of adults are interviewed for the supplemental BRFSS, for a total of roughly 5,000 survey respondents per year for both surveys. The sample size varied each year, ranging from a low of 1,536 in 1996 to a high of 5,755 in 2005. When possible, we used a data set combining the standard and supplemental BRFSS surveys to provide the estimates contained in this report. In cases where questions appeared on only one of the surveys, we used that particular data set. Study measures Demographic measures We asked all respondents to identify their race, ethnicity, age, gender, highest level of formal education achieved, and whether or not children were present in the home. Regarding race and ethnicity, the survey included a question about whether participants were Hispanic or Latino and a separate question about race. For participants who reported more than one race, we also asked about primary race, ‘‘Which one of these groups would you say best represents your race?’’ For this study, the Alaska Native category includes respondents who reported ‘‘Alaska Native/American Indian’’ as their primary or only race group, and the non-Native category includes all other respondents.

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Smoking status and quit ratio We asked all respondents whether they had smoked 100 cigarettes in their lifetimes. For those that responded ‘‘yes’’ (ever smokers) we then asked if they now smoke ‘‘every day, some days, or not at all.’’ Those who responded ‘‘every day’’ or ‘‘some days’’ are considered current smokers. Former smokers are those who had smoked 100 cigarettes, but answered that they now smoke ‘‘not at all.’’ This is a standard smoking measure used in several population-based surveys (14,15). We also assessed the quit ratio, defined as the proportion of former smokers among ever smokers. Consumption We asked current smokers ‘‘On days when you smoked during the past 30 days, about how many cigarettes did you smoke a day?’’ We then examined current some day and every day smokers who report smoking less than 10 cigarettes per day. Stage of change We defined the proportion of current smokers who want to quit smoking by those who answered ‘‘yes’’ to the question, ‘‘Would you like to quit smoking?’’ For those who responded ‘‘yes’’ we then asked if they were seriously considering quitting smoking in the next 6 months. If they responded ‘‘yes,’’ we then asked if they were considering quitting in the next 30 days. Those considering quitting in the next 30 days were considered in the preparation stage of the Stage of Change model (16). Advised to quit We defined the proportion of smokers advised to quit by a health professional by those who answered ‘‘yes’’ to the question, ‘‘In the past 12 months, has a doctor, nurse, or other health professional advised you to quit smoking?’’ We asked this question only of those respondents who had seen a health professional for care in the past 12 months. Awareness of tobacco quit line We asked all respondents if they were aware of the Alaska Tobacco Quit Line, a free telephone service that can help people quit smoking. We assessed the proportion of current smokers aware of the service. Past year quit behavior We combined former smokers who quit 1 year ago or less with all current smokers to examine patterns in past year quit attempts and success. We placed respondents into 3 categories: persons with no quit attempt in the past year, persons with an unsuccessful quit attempt in the past year, and persons with a successful quit attempt in the past year. To examine quit attempts (whether eventually successful or not), we compared the first category to the latter 2 categories combined. To examine quit success, we compared the latter 2 categories to each other.


Smoking-related knowledge, attitudes, and behaviors

Knowledge of the danger of second-hand smoke (SHS) We asked all respondents how harmful they thought SHS is to one’s health. We dichotomized this measure into very harmful versus all else.

smoking-related measures using multiple logistic regression models adjusted for age, gender, and education.

Attitudes about clean indoor air policies We asked all respondents ‘‘In indoor work areas do you think that smoking should be allowed in all areas, in some areas, or not allowed at all?’’ We dichotomized this measure into not allowed at all versus all else. We also asked the same question specifically about restaurants. This variable was also dichotomized into not allowed at all versus all else.

Demographics Compared with non-Natives, Alaska Native people tended to be younger (pB0.001), had less formal education (p B0.001), and were more likely to have children living in the home (p B0.001) (Table I).

Smoking in the home We asked all respondents, ‘‘Which statement best describes the rules about smoking inside your home: smoking is not allowed anywhere inside your home, smoking is allowed in some places or at some times, smoking is allowed anywhere inside your home?’’ We dichotomized this measure into smoking is not allowed anywhere inside home versus all else. Exposure to SHS We asked all respondents if anyone had smoked inside their home in the previous 30 days. We dichotomized this measure into zero days versus one or more days. Smoking in the workplace We asked respondents who reported working indoors most of the time about the official smoking policy at their workplace. We dichotomized this measure into smoking is not allowed in any indoor work area versus all else. Analyses We used data from 1996 to 2010 to examine trends in current smoking prevalence among Alaska Native people and non-Natives. For all other comparisons, we used combined data from 2008 to 2010 to provide the most current estimates of smoking-related knowledge, attitudes, and behavior. For all analyses, we used the 0.05 level of significance and procedures in Stata† that took into account complex sampling design. Data were weighted to adjust for differential sampling rates within each telephone bank and for the number of telephones and adults in the household, and to ensure that the age, gender, and geographic distribution of respondents matched that for all Alaskans based on the Claritas population estimates for a given year (17). We tested for trends during 1996 2010 in current smoking prevalence with logistic regression. Using data from 2008 to 2010, a Pearson chi-square test with Rao and Scott second-order correction was used to determine whether age, gender, education, and presence of children in the home varied by race (Alaska Native people versus non-Native). Also using 20082010 data, we tested for associations between race and

Results

Smoking-related indicators The current smoking prevalence among Alaska Native people was more than twice that of non-Natives (Table II). Although smoking prevalence has declined among nonNatives (pB0.001), no significant decline has been observed among Alaska Native people (p0.33) (Fig. 1). The odds of having ever smoked were significantly higher for Alaska Native people than non-Natives (Table II). Among ever smokers, the odds of being a Table I. Characteristics of Alaska Native and non-Native adults, BRFSS 20082010 (N 12,948) Alaska Native N

Percent*

Non-Native N

Percent*

Age

B0.001

1824

209

16.8

476

12.1

2534

440

24.4

1,431

21.5

3544

422

18.2

1,875

19.2

4554

552

19.8

2,534

20.7

5564

427

12.3

2,304

15.8

65 and older

247

8.5

1,690

10.7

1,054

50.8

4,742

52.0

1,289

49.2

5,659

48.1

454

20.8

492

5.4

1,102

46.1

2,677

27.8

College 13 years

554

23.7

3,196

30.2

College graduate

225

9.3

4,022

36.5

Gender Male Female

0.52

Highest education Less than high

p

B0.001

school graduate High school graduate or GED

Children in the

B0.001

home** No children in

432

35.7

2,972

54.7

587

64.3

1,743

45.3

home Children living in the home *Percent estimates weighted to adjust for sampling design, gender, and age; counts are unweighted. **Sample size is smaller because this measure was only on the supplemental BRFSS survey.


177


Table II. Prevalence of smoking and related indicators among Alaska Native and non-Native adults, BRFSS 20082010 Indicator

Sample size

Prevalence (95% CI)

Adjusted OR (95% CI)

Current smokers Alaska Native Non-Native Ever smokers Alaska Native

2,313

41.1% (37.944.4)

2.3 (1.92.7)

10,330

17.1% (15.918.4)

Referent

2,313

67.7% (64.770.5)

2.1 (1.82.5)

10,330

44.5% (42.946.0)

Referent

Alaska Native

1,604

39.3% (35.643.1)

0.6 (0.50.7)

Non-Native

4,924

61.5% (59.263.8)

Referent

915 1,746

67.7% (62.572.5) 70.5% (66.874.0)

0.8 (0.61.1) Referent

Alaska Native

254

49.7% (37.761.8)

5.0 (2.69.6)

Non-Native

533

22.6% (16.430.4)

Referent

99

91.5% (83.295.9)

1.2 (0.43.2)

204

90.5% (85.094.2)

Referent

Non-Native Former smokers among ever smokers (quit ratio)

Current smokers who smoke every day Alaska Native Non-Native Every day smokers who smoke B10 cigarettes per day

Someday smokers who smoke B10 cigarettes per day Alaska Native Non-Native

Note: Counts are unweighted; percentages are weighted. Odds ratios are adjusted for age, gender, and education.

former smoker (quit ratio) were significantly lower for Alaska Native people. Alaska Native current smokers were as likely to be every day smokers as non-Native current smokers. However, among every day smokers, Alaska Natives had 5 times the odds of smoking less than 10 cigarettes per day. Among some day smokers, Alaska

Native and non-Native smokers had the same odds of smoking less than 10 cigarettes per day.

Cessation-related indicators Alaska Native smokers had similar odds of wanting to quit smoking and planning to quit smoking in the next

Fig. 1. Trends in adult current smoking prevalence, Alaska BRFSS 19962010.

178



30 days as non-Native smokers (Table III). Alaska Native smokers had decreased odds of being advised by a health professional to quit smoking, although the estimate was not statistically significant (p0.08). Alaska Native smokers were as likely as non-Native smokers to be aware of the Alaska Tobacco Quit Line. Compared with nonNatives, Alaska Native smokers were as likely to make a quit attempt but were significantly less likely to quit successfully.

SHS-related indicators Among smokers and non-smokers, Alaska Native people were significantly more likely to believe that SHS is very harmful (Table IV). Alaska Native smokers and nonsmokers were also significantly more likely to agree that smoking should not be allowed at all in indoor work areas and in restaurants. Alaska Native smokers and non-smokers were significantly more likely to have both a home smoking ban and no home exposure to SHS in the past 30 days as compared to non-Native smokers and non-smokers (Table IV). In the workplace, Alaska Native smokers were less likely to have a smoking ban, although this association did not reach statistical significance (p0.12). Among non-smokers, there was no significant difference between Alaska Natives and non-Natives in the likelihood of having a workplace smoking ban.

Discussion Although the disparity in smoking among Alaska Native people continues to persist*twice as many Alaska Native people smoke cigarettes compared with nonNatives*our results suggest that Alaska Native people have knowledge, attitudes, and behaviors that could support reductions in the burden of smoking. For example, Alaska Native every day smokers consume fewer cigarettes per day than non-Native smokers, potentially indicating lower addiction levels (18). In addition, they are equally likely to want to quit, to be ready to quit, and to actually attempt to quit as nonNative smokers. However, Alaska Native smokers had half the odds of making a successful quit attempt compared to non-Natives. These findings contradict other evidence that lower addiction levels are associated with lower risks of relapse after a quit attempt (19). Finding ways to address relapse triggers such as stress and depression, which are high in Alaska Native people (20,21), could be helpful. In addition, awareness of the Alaska Tobacco Quit Line was high among Alaska Native smokers. In a separate study, Alaska Native users of the Quit Line had high quit rates (22%) and nearly all (90%) reported satisfaction with the service, but the service was underutilized by Alaska Native smokers (22). Further outreach could be done to increase use of the Tobacco Quit Line or to explore

Table III. Cessation-related indicators among Alaska Native and non-Native adults, BRFSS 20082010 Indicator

Sample size

Prevalence (95% CI)


356

76.6% (68.982.8)

0.9 (0.51.5)

731

77.1% (71.681.9)

Referent

Alaska Native

169

46.3% (31.961.4)

1.0 (0.52.0)

Non-Native

385

47.4% (39.355.7)

Referent

Alaska Native

198

62.0% (51.971.1)

0.6 (0.31.1)

Non-Native

513

71.4% (64.477.5)

Referent

388 762

72.4% (65.078.7) 69.4% (63.474.9)

1.1 (0.71.7) Referent

Alaska Native

433

69.4% (62.375.7)

1.4 (0.92.1)

Non-Native

893

63.7% (58.069.0)

Referent

Alaska Native

272

11.9% (7.717.9)

0.5 (0.20.9)

Non-Native

562

23.6% (18.030.2)

Referent

Current smokers who want to quit Alaska Native Non-Native Current smokers planning to quit in next 30 days

Current smokers advised by health professional to quit*

Current smokers aware of Quit Line Alaska Native Non-Native Past-year smokers who attempted to quit**

Past-year smokers with successful quit attempt***

Note: Counts are unweighted; percentages are weighted. Odds ratios are adjusted for age, gender, and education. *Among current smokers who have seen a health care professional in the past year. **Quit attempts include those both successful and unsuccessful. Comparison group was past-year smokers with no quit attempt. ***Among past-year smokers with a quit attempt; Comparison group was past-year smokers with an unsuccessful quit attempt. Citation: Int J Circumpolar Health 2013, 72: 21141 - http://dx.doi.org/10.3402/ijch.v72i0.21141

179


Table IV. Second-hand smoke-related indicators among Alaska Native and non-Native adults, BRFSS 20082010 Indicator

Sample size

Prevalence (95% CI)


Believe second-hand smoke is very harmful Current smokers

Alaska Native

391

71.1% (63.677.7)

4.5 (2.87.2)

Non-smokers

Non-Native Alaska Native

771 617

35.5% (29.542.0) 77.3% (72.281.7)

Referent 1.8 (1.32.5)

3,920

66.1% (63.768.5)

Referent 1.9 (1.13.1)

Non-Native

Believe that smoking should not be allowed in indoor work areas Current smokers Non-smokers

Alaska Native

385

73.5% (65.880.0)

Non-Native

741

63.3% (57.369.0)

Referent

Alaska Native

599

91.5% (87.694.2)

1.8 (1.12.9)

3,823

88.6% (86.790.2)

Referent 4.2 (2.56.9)

Non-Native Believe that smoking should not be allowed in restaurants Current smokers Alaska Native Non-smokers

383

82.9% (77.187.4)

Non-Native

755

58.5% (52.264.5)

Referent

Alaska Native

605

92.0% (89.094.3)

2.1 (1.43.1)

3,846

85.7% (83.987.4)

Referent

Alaska Native

388

85.4% (80.689.2)

2.5 (1.63.9)

Non-Native

768

68.1% (62.873.0)

Referent

609 3,891

96.6% (94.897.8) 94.9% (93.895.9)

2.0 (1.23.4) Referent

Alaska Native

389

86.0% (81.089.9)

2.3 (1.53.6)

Non-Native

770

70.5% (65.375.2)

Referent

Alaska Native

613

97.4% (95.698.4)

1.9 (1.03.6)

3,917

96.6% (95.697.4)

Referent

273 555

50.0% (38.761.4) 67.7% (59.974.6)

0.6 (0.41.1) Referent

425

80.8% (75.185.4)

0.9 (0.61.4)

2,836

84.4% (81.986.6)

Referent

Non-Native Home smoking ban Current smokers Non-smokers

Alaska Native Non-Native

No home second-hand smoke exposure in past 30 days Current smokers Non-smokers

Non-Native Workplace smoking ban Current smokers


Non-smokers


Note: Counts are unweighted; percentages are weighted. Odds ratios are adjusted for age, gender, and education.

alternative cessation interventions in the context of a public health approach. Taken together, these findings provide important information about how to tailor cessation and relapse prevention efforts in this population. We found it encouraging that a much larger proportion of Alaska Native smokers had knowledge regarding the harms of SHS and very favourable attitudes regarding smoke-free environments in their communities compared with nonNative smokers. Further, Alaska Native smokers were more likely to have home smoking bans. This suggests that public health messages regarding the harms of SHS are reaching the Alaska Native population, and that social norms regarding tobacco may be changing in this population. However, we observed that Alaska Native smokers might be less likely to work in smoke-free environments. Because smoke-free environments support cessation (23,24), this is an area that should be specifically investigated.

180

Limitations This study has several limitations. First, the BRFSS excludes individuals who live in homes without landline telephones, those who live in institutions, and those who do not speak English. As noted in a recent study of Alaska Native people, 8% of Alaska Native respondents spoke only native languages (25). These Native people would not be captured in the Alaska BRFSS, which is given only in English, and their smoking related knowledge, attitudes, and behavior may be different than those of Alaska Native people who speak English. Second, Alaska Native people might be reluctant to report behaviors and attitudes that others might not find acceptable (particularly over the telephone to a stranger). For example, in another study utilization rates of the Alaska Tobacco Quit Line were lower among Alaska Native smokers compared with non-Native smokers, suggesting that Alaska Natives may be uncomfortable revealing personal information over the telephone (22). Future researchers may



want to investigate this potential limitation by comparing results obtained through different data collection strategies.

Conclusions Despite the large disparity in current smoking prevalence, Alaska Native people living in Alaska have smokingrelated knowledge, attitudes, and behaviors that suggest they want to quit and strongly support smoke-free environments. Public health programs should continue to monitor and explore patterns in quit behaviors including relapse in this population. Additionally, in order to achieve smoking prevalence reductions, efforts should explore culturally appropriate ways to promote cessation and to prevent relapse among Alaska Native smokers, and to build upon the strong preference among Alaska Native people for smoke-free environments.

Acknowledgements This work was funded by the Alaska Tobacco Prevention and Control Program, Alaska Department of Health and Social Services. The program is supported through excise tax revenues and Master Settlement Agreement funds.


References 1. Alaska Department of Health and Social Services. Alaska tobacco facts April 2012 update [cited 2012 Nov 16]. Available from: http://www.dhss.alaska.gov/dph/chronic/documents/ tobacco/pdf/2012_alaska_tobacco_facts.pdf 2. Centers for Disease Control and Prevention. Current cigarette smoking among adults*United States, 2011. Morbidity Mortality Weekly Rep. 2012;61:88994. 3. Caraballo RS, Yee SL, Gfoerer J, Mirza SA. Adult tobacco use among racial and ethnic groups living in the United States, 20022005. Prev Chronic Dis. 2008;5:19. 4. Fagan P, Moolchan ER, Lawrence D, Fernander A, Ponder PK. Identifying health disparities across the tobacco continuum. Addiction. 2007;102:529. 5. Kaplan SD, Lanier AP, Merritt RK, Siegel PZ. Prevalence of tobacco use among Alaska Natives: a review. Prev Med. 1997;26:4605. 6. Kim SY, England L, Dietz PM, Morrow B, Perham-Hester KA. Prenatal cigarette smoking and smokeless tobacco use among Alaska Native and white women in Alaska, 19962003. Matern Child Health J. 2009;13:6529. 7. Renner CC, Patten CA, Day GE, Enoch CC, Schroeder DR, Offord KP, et al. Tobacco use during pregnancy among Alaska Natives in western Alaska. Alaska Med. 2005;47:126. 8. Angstman S, Patten CA, Renner CC, Simon A, Thomas JL, Hurt RD, et al. Tobacco and other substance use among Alaska Native youth in western Alaska. Am J Health Behav. 2007;31:24960. 9. Dent CW, Maher JE, Pizacani BA, Dowler DW, Rohde K, Peterson E. Second-hand smoke exposure in Alaskan households with children. Rural Remote Health. 2010;10:1564.

10. Renner CC, Patten CA, Enoch C, Petraitis J, Offord KP, Angstman S, et al. Focus groups of Y-K Delta Alaska Natives: attitudes toward tobacco use and tobacco dependence interventions. Prev Med. 2004;38:42131. 11. Renner CC, Enoch E, Patten CA, Ebbert JO, Hurt RD, Moyer TP, et al. Iq’mik: a form of smokeless tobacco used among Alaska Natives. Am J Health Behav. 2005;29:58894. 12. Renner CC, Lanier AP, Lindgren B, Jensen J, Patten CA, Parascandola M, et al. Tobacco use among southwestern Alaska Native people. Nicotine Tob Res. 2013;15:4016. 13. Alaska Behavioral Risk Factor Surveillance Survey [cited 2012 Nov 14]. Available from: http://www.dhss.alaska.gov/dph/chronic/ pages/brfss/method.aspx 14. Centers for Disease Control and Prevention. National health interview survey [cited 2013 Feb 26]. Available from: http:// www.cdc.gov/nchs/nhis.htm 15. National Cancer Institute. Tobacco use supplement of the current population survey [cited 2013 Feb 26]. Available from: http://riskfactor.cancer.gov/studies/tus-cps/ 16. Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot. 1997;12:3848. 17. Nielsen Claritas Site Reports [cited 2012 Nov 13]. Available from: http://www.claritas.com/sitereports/default.jsp 18. Chabrol H, Niezborala M, Chastan E, DeLeon J. Comparison of the heavy smoking index and of the Fagerstrom test for nicotine dependence in a sample of 749 cigarette smokers. Addict Behav. 2005;30:14747. 19. Sweitzer MM, Denlinger RL, Donny EC. Dependence and withdrawal-induced craving predict abstinence in an incentivebased model of smoking relapse. Nicotine Tob Res. 2013;15: 3643. 20. McKee SA, Sinha R, Weinberger AH, Sofuoglu M, Harrison EL, Lavery M, et al. Stress decreases the ability to resist smoking and potentiates smoking intensity and reward. J Psychopharmacol. 2011;25:490502. 21. Dillard DA, Smith JJ, Ferucci ED, Lanier AP. Depression prevalence and associated factors among Alaska Native people: the Alaska Education and Research Toward Health (EARTH) study. J Affect Disord. 2012;136:108897. 22. Boles M, Rohde K, He H, Maher JE, Stark MJ, Fenaughty A, et al. Effectiveness of a tobacco quitline in an indigenous population: a comparison between Alaska Native people and other first-time quitline callers who set a quit date. Int J Circumpolar Health. 2009;68:17081. 23. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General. Washington, DC: U.S. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health, 2006. 24. National Cancer Institute (2000). Population based smoking cessation: proceedings of a conference on what works to influence cessation in the general population. Smoking and Tobacco Control Monograph No. 12. 25. Schumacher MC, Slattery ML, Lanier AP, Ma KN, Edwards S, Ferucci ED, et al. Prevalence and predictors of cancer screening among American Indian and Alaska Native people: the EARTH study. Cancer Causes Control. 2008;19:72537. *Kristen Rohde 827 NE Oregon Street, Suite 250 Portland, OR 97232 USA Tel: 1 971 673 0592 Email: [email protected]


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Attitudes toward harm reduction and abstinence-only approaches to alcohol misuse among Alaskan college students Monica C. Skewes1* and Vivian M. Gonzalez2 1

Department of Psychology, Center for Alaska Native Health Research, University of Alaska Fairbanks, Fairbanks, AK, USA; 2Department of Psychology, University of Alaska Anchorage, Anchorage, AK, USA

Background. Harm reduction is a public health approach that aims to guide hazardous drinkers to change unsafe drinking and minimize alcohol-related consequences without requiring abstinence. In contrast, abstinence-based interventions are designed for people with more severe alcohol problems and they aim to eliminate consequences via complete abstinence from alcohol. Current best practices for treating college student alcohol misuse involve harm reduction strategies, but no research has been conducted examining students’ perceptions of these strategies. Objective. Understanding attitudes is critical prior to the implementation of an intervention in a new setting, particularly when attitudes may serve as barriers to treatment enrolment and retention. For this reason, we sought to examine attitudes toward contrasting alcohol misuse interventions among college students in two large public universities in the circumpolar north. Design. A web-based survey was conducted with 461 students from two public universities in Alaska. Participants completed questionnaires assessing attitudes toward alcohol treatment, current drinking behavior, and demographic information. Results. Findings indicated that emerging adult (1825 years old) students who would be targets of future interventions (hazardous drinkers) evidenced more positive attitudes toward harm reduction than abstinenceonly approaches. Conclusion. This research provides support for the implementation of harm reduction intervention strategies for Alaskan college students who misuse alcohol. It is likely that harm reduction will be acceptable in this population. Keywords: hazardous drinking; treatment strategies; emerging adults

early half of U.S. college students report engaging in binge drinking (5 drinks on one occasion for men or 4 for women) within the past 2 weeks (1,2). It has been estimated that 31% of college students have symptoms consistent with a diagnosis of alcohol abuse and 6% with alcohol dependence (3). Heavy drinking in this population is associated with a number of serious consequences, including academic, health, legal, and social problems (4). Despite these consequences, alcohol misuse remains a common occurrence among college students and is a national public health concern (5). Harm reduction (HR) is a public health approach that aims to guide problem drinkers to change unsafe drinking and minimize alcohol-related consequences without requiring abstinence (6,7). It aims to intervene before alcohol misuse develops into a more severe alcohol use disorder and, hence, is a form of secondary prevention. HR may include activities such as moderating alcohol

N

182

consumption, engaging in protective behavioral strategies such as using a designated driver, changing one’s thinking about alcohol use, learning and practicing drink refusal skills, and challenging alcohol-related social norms and expectancies. Abstinence-based interventions also are used to address problem drinking behavior but instead advocate complete avoidance of alcohol and alcohol-related cues to eliminate problems associated with excessive drinking. Abstinence is not incompatible with HR, but the decision regarding the goal of HR interventions (abstinence or controlled drinking) is left to the individual, and techniques meant to facilitate abstinence, such as the avoidance of drinking cues, are not emphasized. Abstinence-only (AO) and HR approaches both have been useful for improving health outcomes among people engaging in hazardous drinking; however, current best practices for treating college student alcohol misuse involve HR strategies (8).


Alcohol treatment attitudes

Although few studies have examined attitudes toward HR among substance use disorder patients, findings suggest that clients’ beliefs about the need for abstinence affect preference for a moderation goal (9). Those who are younger (10), have less severe alcohol dependence (11), and greater social support for drinking (9) are more likely to select moderation than abstinence as a treatment goal. These characteristics describe college student drinkers; however, no published study to date has explored attitudes toward HR and AO interventions. The current study fills this gap in the literature by reporting on attitudes toward HR and AO treatment modalities in a sample of college students in the circumpolar north. Understanding attitudes toward different treatment approaches is important for improving the social validity and acceptability of interventions. For example, knowing how acceptable and appealing HR and AO strategies are to potential intervention participants can guide and inform future intervention efforts, and understanding factors that affect attitudes toward these treatment strategies can provide an evidence base for matching intervention approaches to client characteristics. This formative research constitutes a first step toward determining the type, components, and aspects of interventions that might be needed for Alaskan college students.

Method Participants Participants were 461 college student females (73.5%, n 339) and males (26.5%, n 122) attending large, open enrolment universities in Alaska. Students were surveyed from two universities, each providing approximately half the participants in the final sample (51.4 and 48.6%). Measures Treatment Attitudes Scale (TAS) At the time of this study, there was no published assessment instrument to examine attitudes toward HR and AO alcohol intervention techniques. Therefore, for the purposes of this study, the authors generated 46 items to assess participants’ attitudes toward the effectiveness of techniques that primarily are associated with either HR (e.g. ‘‘when you drink, try and space your drinks out’’) or AO (e.g. ‘‘completely avoid places you used to drink’’) interventions. Items representing the intervention strategies were rated for perceived effectiveness on a fivepoint scale from 1 (not at all likely to be effective) to 5 (very likely to be effective). Participants were provided the following directions: ‘‘There are many ways to manage problematic alcohol use. Imagine that you have an alcohol problem. Below are different types of things that you could do to try to change your problem. Rate how effective you think each strategy would be if you had an alcohol problem.’’

Participants also completed a companion measure of self-efficacy for HR and AO intervention techniques. This companion self-efficacy measure consisted of the same 46 items that were rated for effectiveness, but the instructions and response options were different. Instead of asking how effective each strategy would be, the companion measure asked how confident participants were that they could successfully perform each strategy, rated on a fivepoint scale from 1 (not at all confident) to 5 (extremely confident). Before using the TAS in this study, analyses were conducted to examine the psychometric properties of the instrument. An exploratory factor analysis using principal components analysis with equamax rotation resulted in a two-factor solution representing HR and AO techniques. Items with cross loadings (0.30) or loadings below 0.50 were eliminated, resulting in 13 items per subscale. Loadings ranged from 0.56 to 0.78 on HR and 0.51 to 0.81 on AO. These subscales had high internal consistency with alpha coefficients of 0.93 for HR and 0.92 for AO. The self-efficacy companion measure also was subjected to a principal components analysis with equamax rotation, resulting in a two-factor solution representing HR and AO. The same items as those in the effectiveness subscales were retained, with few cross loadings evident. A total of five items with cross loading and one item with a loading below the previously used cut-off of 0.50 (0.47) were retained to allow direct comparison between the HR and AO scales. Loadings ranged from 0.61 to 0.74 on HR and 0.47 to 0.85 on AO. Self-efficacy subscale coefficient alphas were 0.93 for HR and 0.92 for AO.

Hazardous drinking The Alcohol Use Disorder Identification Test Consumption (AUDITC; 12) was used to categorize people as hazardous drinkers or non-hazardous drinkers. The AUDITC is comprised of three self-report items measuring: (a) frequency of drinking, rated from 0 (never) to 4 (four or more times per week); (b) drinks per drinking day, rated from 0 (1 or 2) to 4 (10 or more); and (c) frequency of having 6 standard drinks on one occasion, rated from 0 (never) to 4 (four or more times per week). Items are summed to yield a total score, with higher scores indicating a greater likelihood of having an alcohol use disorder. Male participants who scored ]4 and female participants who scored ]3 were classified as hazardous drinkers (13). Demographics Participants were instructed to indicate their age, gender, and ethnicity. Regarding age, participants were classified as either emerging adults (1825 years old) or adults over age 25. Research suggests that emerging adulthood is an especially risky time for developing alcohol problems (14), and traditionally college students are in this age range.


183

Monica C. Skewes and Vivian M. Gonzalez

Both universities sampled for this study have a higher proportion of non-traditional college students who are over the age of 25 than is typical; therefore, we explored potential age differences in attitudes.

Procedure The study protocol was approved by the institutional review boards of both universities where the study was conducted. Participants were recruited via a university web-based research portal and via in-class announcements and received extra course credit for their time and effort. Participants were given the link to the online survey and instructed to visit the web page to give electronic informed consent and complete the survey. Analyses Separate 23 mixed between-within-subjects analyses of covariance were conducted on (a) perceived effectiveness and (b) self-efficacy for the intervention strategies. The within-subjects independent variable was intervention type (HR, AO) and the between-subjects independent variables were hazardous drinking (non-hazardous drinker/non-drinker, hazardous drinker) and stage of adulthood (emerging adult, adult over 25). Gender was entered as a covariate in all analyses. A main effect for intervention was examined first. Then we examined interactions between intervention and gender, intervention and stage of adulthood, and intervention and hazardous drinking. Finally, we examined a three-way interaction between intervention, stage of adulthood, and hazardous drinking. SPSS version 19 was used to analyze the data, and alpha was set at 0.05.

Results Six hundred thirty participants initiated the online survey. Participants with missing data (n92), those with invariant responding (n 7), those who took less than 30 minutes to complete the survey (n 39), and those who took more than 4 hours (n 31) were eliminated. Analyses were conducted with the remaining 461 participants.

Participants’ mean age was 23.7 years old (SD 6.7), with a range from 18- to 54-years-old. The sample was 70.1% White/European American, 8.5% Alaska Native or American Indian, 7.2% Asian, 5.2% Hispanic/Latino, 4.8% African American, 2.6% mixed race/ethnicity, and 1.8% were other ethnic minorities or refused to answer. The majority of participants were full-time students (85.3%). The sample was 24.3% freshman, 23.4% sophomore, 22.3% junior, 27.8% senior, and 2.2% graduate students. In this sample, 20.2% (n 93) reported not drinking and 79.1% (n 368) reported drinking at least once a month. A little over half of participants reported drinking six or more drinks on one occasion at least once a month (54.7%, n 252) and 42.1% (n 194) were hazardous drinkers based on AUDITC cut-off scores. Non-drinkers were classified as non-hazardous drinkers in the analyses. Means, standard deviations, and correlations among the study variables are presented in Table I.

Effectiveness For the analysis of covariance (ANCOVA) examining perceived effectiveness, no significant main effect was found for intervention type, F(1,456) 1.68, p 0.195, h2 0.003. However, significant interactions were found between intervention type and both stage of adulthood, F(1,456) 13.28, p B0.001, h2 0.027, and hazardous drinking group, F(1,456) 17.12, p B0.001, h2 0.034. There also was a significant three-way interaction between intervention, hazardous drinking, and stage of adulthood, F(1,456) 8.47, p0.004, h2 0.017. Gender did not significantly interact with intervention type, F(1,456) 0.32, p 0.57, h2 0.001. To further examine these interaction effects, separate ANCOVAs examining the perceived effectiveness of intervention were conducted for hazardous drinking groups by stage of adulthood (see Table II). These analyses revealed that for non-hazardous drinking adults over 25 years of age, abstinence-only was perceived as much more effective than HR, F(164)18.77, p B0.001, h2 0.226. In contrast, for emerging adult hazardous

Table I. Means, standard deviations, and intercorrelations of study variables Variables

M

SD

1

2

3

4

5

6

1. EffectivenessAO techniques 2. EffectivenessHR techniques

3.51 3.52

0.87 0.82

0.39***

3. Self-efficacyAO techniques

3.12

0.90

0.38***

0.14**

4. Self-efficacyHR techniques

3.67

0.81

0.17***

0.60***

5. Stage of adulthood

0.02

0.20***

0.05

0.10*

6. Hazardous drinking

0.15**

0.00

0.32***

0.02

0.03

7. Gender

0.13**

0.07

0.01

0.06

0.11*

0.46***

0.01

N 461. AO abstinence-only, HRharm reduction. Stage of adulthood was coded: emerging adult/1825 years 0.26 years1. Gender was coded: men 1, women0. *pB0.05, **p B0.01, ***p B0.001.

184


Alcohol treatment attitudes

Table II. Effectiveness and self-efficacy for intervention techniques according to stage of adulthood and hazardous drinking Emerging adult (1825)

Adult (26)

Non-hazardous (n201)

Hazardous drinker (n151)

Non-hazardous (n66)

Hazardous drinker (n43)

Mean (SD)

Mean (SD)

Mean (SD)

Mean (SD)

AO techniques

3.59 (0.89)a

3.38 (0.80)a

3.71 (0.91)a

3.28 (0.87)a

HR techniques

3.65 (0.83)a

3.56 (0.71)b

3.11 (1.01)b

3.39 (0.62)a

AO techniques

3.31 (0.84)a

2.81 (0.78)a

3.54 (0.99)a

2.65 (0.90)a

HR techniques

3.74 (0.85)b

3.66 (0.64)b

3.48 (1.05)a

3.60 (0.69)b

Variables Effectiveness

Self-efficacy

AO abstinence-only, HR harm reduction. For effectiveness and self-efficacy variables (separately), means in the same column with different subscripts are significantly different.

drinkers, HR was perceived as moderately more effective than AO, F(1,149) 6.14, p 0.014, h2 0.040. There were no significant differences in the perceived effectiveness of HR and AO for emerging adult non-hazardous drinkers, F(1,199) 0.54, p 0.462, h2 0.003, or for hazardous drinkers over the age of 25, F(1,456) 0.033, p 0.857, h2 0.001.

Self-efficacy For the ANCOVA examining self-efficacy, a large significant main effect was found for intervention type, F(1,456) 121.55, p B0.001, h2 0.187. Significant interactions were found between intervention type and both stage of adulthood, F(1,456) 4.69, p 0.031, h2 0.007, and hazardous drinking group, F(1,456) 56.78, p B 0.001, h2 0.087. There also was a significant three-way interaction between intervention, hazardous drinking, and stage of adulthood, F(1,456) 9.96, p 0.002, h2 0.015. Gender did not significantly interact with intervention type, F(1,456) 1.88, p0.171, h2 0.003. To further examine these interaction effects, separate ANCOVAs examining self-efficacy for using the intervention techniques were conducted for hazardous drinking groups by stage of adulthood (see Table II). For nonhazardous drinkers over the age of 25, there was no significant difference in self-efficacy between HR and AO, F(1,64)0.025, p 0.876, h2 000. However, for hazardous drinkers over 25, self-efficacy for HR techniques was significantly higher than for AO techniques with a large effect size, F(1,41)31.04, p B0.001, h2 0.427. Selfefficacy for using HR techniques also was much greater than for AO techniques for emerging adults who were nonhazardous drinkers, F(1,199) 43.63, p B0.001, h2 0.179, as well as for those who were hazardous drinkers, F(1,149) 145.81, p B0.001, h2 0.492.

Discussion Significant differences in attitudes toward HR and AO were found based on drinking status and age group.

Students in the older age group (26) who were nonhazardous drinkers perceived AO to be more effective than HR; however, hazardous drinkers in this age group perceived both treatments as equally effective but reported significantly greater self-efficacy in their ability to perform HR strategies. Among emerging adults, nonhazardous drinkers also perceived the approaches to be equally effective and reported significantly greater selfefficacy for HR. However, emerging adult hazardous drinkers reported both greater perceived effectiveness and greater self-efficacy for HR than for AO intervention techniques. These findings provide strong support for the acceptability of HR interventions for alcohol misuse among college students who are hazardous drinkers. Hazardous drinkers in both age groups had greater self-efficacy for using HR compared with AO techniques, and emerging adults also viewed HR as more effective. Alcohol interventions on college campuses target hazardous drinkers, and most college students are emerging adults (15). Therefore, the findings that emerging adult hazardous drinkers perceive HR as more effective and report greater self-efficacy for HR indicate that this type of intervention is more likely to be accepted by this at-risk group. It is interesting to note that, with the exception of older students who are not hazardous drinkers, students generally had greater self-efficacy for HR than AO, even when they did not perceive HR as more effective than AO. It makes sense that students in the alcohol-promoting college environment would feel greater confidence in their ability to moderate their drinking than to avoid alcohol and alcohol-related cues altogether. Because research shows that self-efficacy predicts success in alcohol treatment (16), it is noteworthy that self-efficacy was greater for HR for most students and for all hazardous drinkers. Because interventions will be designed for and targeted to hazardous drinkers, the greater self-efficacy for HR supports the use of HR approaches to treatment.


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Limitations and future directions This research constituted a first step toward developing an alcohol misuse intervention that will be accepted by and effective for college students in Alaska. Instead of transporting existing manualized interventions from other parts of the world, the authors decided to engage in careful a priori research to determine which programs or aspects of programs might be needed in Alaska. To do this, we first needed to understand the attitudes of students who may be targets of future interventions. We gained valuable information about strategies that students think would be effective for reducing alcohol misuse and problems and that they also feel confident they could perform. This research suggests that HRwould be a better approach than AO for addressing alcohol misuse among Alaskan college students. A limitation of the current research is the overrepresentation of female college students and underrepresentation of Alaska Native college students compared to the overall population of Alaskan college students. Ongoing research is being conducted to explore attitudes solely among Alaska Native students who drink. It also is important to note that attitudes do not necessarily predict outcome. Having positive attitudes toward HR does not ensure that an HR intervention will be effective. However, having negative attitudes toward HR would be a significant barrier to the successful enrolment and retention of participants in an HR intervention. Therefore, positive attitudes are necessary, but not sufficient, for intervention to be successful. Future research will be conducted to qualitatively explore students’ attitudes toward alcohol misuse interventions, with special attention paid to the perceptions of Alaska Native students who may have culturally distinct experiences with and perceptions of alcohol. Ultimately, an HR intervention that is acceptable and appropriate for college students in Alaska will be implemented and evaluated.

Acknowledgements Research reported in this publication was supported by the National Institute of General Medical Sciences of the National Institutes of Health under award number P30GM103325. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Conflicts of interest and funding The authors have no conflicts of interest

3. Knight JR, Wechsler H, Kuo M, Seibring M, Weitzman ER, Schuckit MA. Alcohol abuse and dependence among U.S. college students. J Stud Alcohol. 2002;63:26370. 4. Hingson R, Heeren T, Winter M, Wechsler H. Magnitude of alcohol-related mortality and morbidity among U.S. college students ages 1824: changes from 1998 to 2001. Annu Rev Public Health. 2005;26:25979. 5. Alexander EN, Bowen AM. Excessive drinking in college: behavioral outcome, not binge, as a basis for prevention. Addict Behav. 2004;29:1199205. 6. Larimer ME, Marlatt GA, Baer JS, Quigley LA, Blume AW, Hawkins EH. Harm reduction for alcohol problems: expanding access to and acceptability of prevention and treatment services. In: Marlatt GA, Marlatt GA, editors. Harm reduction: pragmatic strategies for managing high-risk behaviors. New York: Guilford Press; 1998. p. 69121. 7. Marlatt GA, Witkiewitz K. Harm reduction approaches to alcohol use: health promotion, prevention, and treatment. Addict Behav. 2002;27:86786. 8. Walters ST, Baer JS. Talking with college students about alcohol: motivational strategies for reducing abuse. New York: Guilford Press; 2006. 9. Heather N, Adamson SJ, Raistrick D, Slegg GP. Initial preference for drinking goal in the treatment of alcohol problems: I. baseline differences between abstinence and nonabstinence groups. Alcohol Alcohol. 2010;45:12835. 10. Hodgins DC, Leigh G, Milne R, Gerrish R. Drinking goal selection in behavioral self-management treatment of chronic alcoholics. Addict Behav. 1997;22:24755. 11. Adamson SJ, Sellman JD. Drinking goal selection and treatment outcome in out-patients with mild-moderate alcohol dependence. Drug Alcohol Rev. 2001;20:3519. 12. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDITC). Arch Intern Med. 1998;158:178995. 13. Reinert DF, Allen JP. The alcohol use disorders identification test (AUDIT): a review of recent research. Alcohol Clin Exp Res. 2002;26:2729. 14. Arnett JJ. Emerging adulthood: the winding road from the late teens through the twenties. New York: Oxford University Press; 2004. 15. U.S. Census Bureau. School enrollment in the United States: 2008; 2011 [cited 2013 Feb 27]. Available from: http://www. census.gov/prod/2011pubs/p20-564.pdf 16. DiClemente CC. Self-efficacy and the addictive behaviors. J Soc Clin Psychol. 1986;4:30215. *Monica C. Skewes Department of Psychology Center for Alaska Native Health Research University of Alaska, Fairbanks 902 N. Koyukuk, Room 311 Fairbanks, AK 99775-7000 USA Email: [email protected]

References 1. Wechsler H, Nelson TF. Binge drinking and the American college student: what’s five drinks? Psychol Addict Behav. 2001;15:28791. 2. McNally AM, Palfai TP. Negative emotional expectancies and readiness to change among college student binge drinkers. Addict Behav. 2001;26:72134.

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Informal and formal mental health: preliminary qualitative findings Linda O’Neill1*, Serena George1, Corinne Koehn1 and Blythe Shepard2 1

Counselling Program, School of Education, University of Northern British Columbia, Prince George, British Columbia, Canada; 2Counselling Program, University of Lethbridge, Lethbridge, Alberta, Canada

Background. Northern-based research on mental health support, no matter the specific profession, helps to inform instruction of new practitioners and practitioners already working in rural or isolated conditions. Understanding the complexities of northern mental health support not only benefits clients and practitioners living in the North, but also helps prepare psychologists and counsellors preparing to work in other countries with large rural and isolated populations. The qualitative phase is part of a multi-year research study on informal and formal mental health support in northern Canada involving the use of qualitative and quantitative data collection and analysis methods. Objective. The main objective of the qualitative phase interviews was to document in-depth the situation of formal and informal helpers in providing mental health support in isolated northern communities in northern British Columbia, northern Alberta, Yukon and Northwest Territories (NWT). The intent of in-depth interviews was to collect descriptive information on the unique working conditions of northern helping practitioners for the development of a survey and subsequent community action plans for helping practitioner support. Design. Twenty participants in northern BC, Yukon and NWT participated in narrative interviews. Consensual qualitative research (CQR) was used in the analysis completed by 7 researchers. The principal researcher and research associate then worked through all 7 analyses, defining common categories and themes, and using selections from each researcher in order to ensure that everyone’s analysis was represented in the final consensual summary. Results. The preliminary results include 7 main categories consisting of various themes. Defining elements of northern practice included the need for generalist knowledge and cultural sensitivity. The task of working with and negotiating membership in community was identified as essential for northern mental health support. The need for revised codes of ethics relevant to the reality of northern work was a major category, as was insight on how to best sustain northern practice. Conclusion. Many of the practitioners who participated in this study have found ways to overcome the biggest challenges of northern practice, yet the limitations of small populations and lack of resources in small communities to adequately address mental health support were identified as existing. Empowering communities by building community capacity to educate, supervise and support formal and informal mental health workers may be the best approach to overcoming the lack of external resources. Keywords: northern; mental health; formal and informal practitioners; qualitative research

n northern British Columbia, Yukon and Northwest Territories (NWT), communities, access to mental health specialists is severely restricted due to the distance from larger centres. The difficult task of providing mental health services and support in remote northern communities is undertaken by both formal and informal mental health practitioners due to geographical, cultural, community and economic necessity (13). Environment determines lifestyle in the North, with geo-

I

graphy influencing practice (4), whether that practice is counselling, psychology, social work, nursing or other helping professions. Features of geography and weather add physical isolation to professional and sometimes personal isolation inherent in mental health support in communities with small populations. Canada’s northern region is very sparsely populated with only about 101,310 individuals living in a vast area larger than Western Europe (5). About 69% of the


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population of the Yukon, NWT and Nunavut is of Aboriginal descent, and these 3 territories each have a greater proportion of Aboriginal inhabitants than any of Canada’s provinces, with Yukon having the largest percentage of non-Aboriginal inhabitants (6). Mental health service provision is challenging throughout the North due to geographical isolation and the resulting remoteness of communities. Transportation difficulties, small community populations and demanding practice conditions make the recruitment of service providers difficult. Mental health services along with other social services have also been cut-back or eliminated in many communities due to fiscal issues experienced by provincial and federal governments, resulting in more responsibility and stress on the few remaining formal helping practitioners and on informal helping support such as lay counsellors, elders, family members and other community helpers. The literature suggests that an understanding of isolated northern cultures is essential for competent practice in such settings (7). This understanding includes the influence of cultural diversity, work and economic factors on the social psychology of northern communities, all topics required for a sound knowledge base (4) for various practitioners, both informal and formal.

Significance This study examined the issues related to northern practice experienced by formal and informal helping practitioners in providing mental health support. The existing research on specific professions and northern practice has presented the various challenges of mental health and wellness work in northern communities including geographical and professional isolation issues. However, there is a lack of ‘‘proactive literature’’ (4) on sustaining supports and future vision for northern mental health practice, looking at opportunities rather than challenges (8). The main focus of this study is how practitioners sustain their practice, and what supports are currently available to help them with longevity in their work in the North.

Research questions In order to better understand mental health and wellness support in the North, the following questions informed the qualitative phase of the research:

Principle research question What are the life-career issues, supports, challenges and barriers for formal and informal helping practitioners in northern communities? For the qualitative phase, this question was simplified and broadened to allow participants to begin the interview where they wanted to start: What is your experience of providing informal or formal mental health and wellness support in northern communities?

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Secondary questions a. What supports and resources would enhance the effectiveness and longevity of such workers? and b. What is the impact of Aboriginal culture on effective helping support and culturally appropriate training and supervision?

Process and method Background The research design allowed for an intense focus on the experience of individual practitioners and helpers living in northern BC and the larger centres of Whitehorse, Yukon and Yellowknife, NWT and other outlying communities. Our intent in the qualitative phase was to first focus in-depth on stories through individual interviews and to gain an understanding of the wider community context in order to use participants’ knowledge and information in the development of a survey to access a broad range of helpers in the North (9). Narrative interviews were chosen for the descriptive, in-depth data collection of data. Josselson et al. (10) suggest that narrative inquiry is capable of creating a description of a historical or personal event that is rich and multilayered. It offers a means of understanding the past in order to go beyond it, of finding the articulation between the influence of external factors and the individual’s initiatives. (11)

Blustein et al. highlight the explanatory nature of this type of inquiry and its capacity to deepen and understand a participant’s lived experience, noting that narratives are ‘‘particularly informative to the psychology of work for individuals who have been outside of the mainstream of career development discourse’’ (12). Career narratives, in particular, have the ability to identify aspects of the social realm that have enabled or constrained individuals (13). The preliminary analysis lists a multitude of social and geographical aspects related to northern mental health support work.

Participants In the qualitative phase, potential participants in BC, Yukon and NWT, were contacted through letters and e-mails to agencies, First Nations governments, nonprofit societies and private practitioners who advertised publicly. Snowball sampling emerged after the initial sending out of information, a phenomenon that evolves in small communities where word-of-mouth communication is common. The research team travelled to the selected territories and province over two summers and one winter to conduct the initial interviews and then do follow-up contact. Interested participants were contacted by the principal investigator to set up the interviews.


Informal and formal mental health

Twenty northern practitioners, including both formal and informal mental health and wellness workers, took part in the in-depth interviews. Due to the need to protect participants’ anonymity during the qualitative phase in contexts where just a few details could potentially identify helpers in small communities, very general demographic information is provided. Participants ranged in age from mid-20s to 65, representing 15 women and 5 men. The formal mental health and wellness practitioners included counsellors and psychologists. The participants who were included in the informal category included professionals in other fields who were providing mental health support such as nurses and social workers, although such work was not part of their official job description, and paraprofessionals who work in child and youth care, corrections and family support positions. Participants were interviewed by the principal investigator in a place of their choosing, ranging from offices, favourite community spots and cafes. Graduate students who were working as research assistants were included in the majority of the interviews as a part of the mentoring process and added their lenses for input on the immediate initial coding. Their presence in the interviews allowed them to bring to life each interview during the transcription and analysis process.

The results of the 7 analyses of the data were shared at a research gathering that resulted in critical reflection about common and divergent themes. The principal researcher and research associate then worked through all 7 analyses, defining common categories and themes, and using selections from each researcher in order to ensure that everyone’s analysis was represented in the final consensual summary. The researchers later verified that they believed their analysis was represented in the first summary of categories and themes. As another verification check in the analysis, we sent participants their transcriptions and a list of individual quotes to receive permission to use. The final step is to send participants the summary for feedback and final verification and then work through a meta-analysis.

Qualitative data analysis The research team, consisting of 3 faculty researchers, 1 research associate and 3 graduate research assistants took part in Consensual Qualitative Research (CQR) analysis. CQR is a rigorous method that allows research teams to examine data, to bring a variety of opinions to each decision and to come to consensus about the meaning of the data so that the best possible construction is developed for all of the data (14). Data analysis by the research team generally involved 3 central steps: (a) clustering data into topics in order to segment interview data into domains; (b) summarizing core ideas that capture each participant’s perspective and meaning; and (c) constructing common themes from each participant story and then across participants (14).

Northern practice Collaboration was defined as a key component to successful northern practice. Cohesive work environments were characterized by open communication, trust and support among colleagues. A team approach in agencies and across disciplines was described as enhancing the health and wellness of practitioners and promoting best practice standards including the continuity of client care. The lack of collaboration with formal mental health services was a concern for some of the practitioners. Confidentiality was viewed as creating barriers in working collaboratively across communities and providing continuity of care because client care plans are not shared with support systems in the clients’ home communities. The little to no sharing of information was

Preliminary results Categories Participants expressed specific experiences directly related to their role in mental health support based on their context of working in northern BC, Yukon or NWT. Seven broad categories are currently identified pending final feedback from the participants on the research summary, comprehensive categories that hold the main ideas expressed in the participant interviews (Table I).

Table I. Preliminary categories, informal and formal mental health support Research question

Categories

What are the life-career issues, supports, challenges, and barriers for formal and informal helping practitioners Northern practice in northern communities? Community What is the impact of Aboriginal culture on effective helping support and culturally appropriate training and supervision? What supports and resources would enhance the effectiveness and longevity of such workers?

Insiders/outsiders Northern challenges Ethical issues Cultural context Sustaining northern practice


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described as a double-edged sword because it is meant to protect clients but was also viewed as impeding the continuity of care. Northern practice was consistently defined as broad, generalist and eclectic because of the diverse population and range of client issues. Participants found it challenging and often overwhelming to work with individuals presenting with multiple diagnoses. Practitioners struggled with knowing where to start with clients who have long histories of abuse by multiple offenders. For example: When you train, you normally talk about a client who comes in with depression you know a, b, c and you work through what would happen. But when your client walks in and you’re like I can’t distinguish one issue from another, it’s like the comorbidity, but it’s everyone you know and complex trauma (10111101).

Participants confirmed that accessing mental health support is often viewed negatively and there has not been enough of a shift away from the hidden nature of mental health issues. One participant questioned how the mindset towards counselling can be shifted to be a source of pride rather than something shameful. For informal helpers, northern practice included the politics of professionalism. The message front-line workers reported receiving is they are not counsellors and they do not have the skills to work with complex issues. One participant addressed this issue: Well you do as much as you can, but like we’re not supposed to open a can of worms, right. So if something is really bugging the kids and you ask them once you have to leave it alone because if you open it, then you’re counselling (10081301).

Community With smaller populations in communities, the requirement to connect with community was considered part of northern practice. The participants emphasized the time and consistency necessary for helpers to build trust in a community: Being in the small community and being able to build relationships with other agencies, I think that’s something that is more difficult in other places, so I think that’s great . . .. They know who you are, they know where you are, they know what you do because we’re small enough (10071601).

Mentorship was identified as a key component for practitioners working in isolated communities. The participants recommended getting acquainted with colleagues and working closely with community advisors and Elders to best address the community needs. Practitioners interviewed strove to represent the community and help people get the supplies and resources they needed.

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The connection with community was described as meaningful and life changing for some of the participants. Practitioners discussed their relationships with other community members and the deep emotional connection to what was happening within their community. You have to find the medium that works for you and maybe that community worked for me and I worked for that community . . . we could create things because of context, place, fate, time you know that kind of piece (10072202).

Insiders/outsiders In concrete terms, an ‘‘insider’’ represents a helper who is considered a long-standing member of the community while an ‘‘outsider’’ is a helper who comes into a community from some other place. In many of the interviews, the constructs of the insider and the outsider emerged as distinct from one another and were discussed in terms of the pros and cons that are associated with helpers who are in either position. Outsiders were described as often lacking an understanding of the broader contexts in which their clients’ issues are positioned. The participants explained that outsiders who come into communities in helping roles bring with them the advantage of a fresh perspective. One participant captured this phenomenon as he described his own experience of being an outsider: I think that’s part of my strength because I am an outsider in a lot of ways, then I can see things with a different perspective. I think that would definitely be an asset to any northern organization to have an outside perspective because it’s very easy just to lose sight of the bigger picture (10110801).

Insiders are often well respected in communities and have established trust over years of being consistent and visible within the community. However, the burden of practice was seen to be very heavy for insider helpers according to the participants because of the degree of enmeshment and expectation that is placed on these helpers. Their connections within their community, through both historical and current associations, was often so wide spread that any client an insider worked with in a helping context, were also connecting that helper through a number of other channels.

Northern challenges Many of the challenges of isolated practice have been identified in previous research (1517). Aspects of social, professional and personal isolation directly linked to geographical components were again discussed by the participants. One of the biggest challenges in the North identified by the practitioners is that the mental health issues are endemic and so deep into the core of the



communities. They described a lack of understanding of mental health issues resulting in stigma and isolation. The high turnover rate in the helping professions was described as an on-going challenge in the territories and northern BC. One practitioner provided an example to illustrate this issue: But constantly having to adapt and to adjust and change and that can be stressful you don’t even realize it after a while. Now we have someone who signed on for a year. A year . . . after a year she’ll be gone, good bye. Before her there was another psychiatrist, signed on for a year. And you know someone was saying to me change is good. I said not always (10111403).

Practitioners were often unable to meet the needs of the clients because of large caseloads and administrative demands. Both informal and formal practitioners addressed concerns regarding the lack of clinical supervision in the North.

Ethical issues The challenging concept of confidentiality became a theme of its own, as did the discussion around codes of ethics and what has to be changed to make those codes appropriate to northern mental health and wellness support. The codes were described by some participants as being from an old model that does not work in the North, with the need for revision for northern practice. It was suggested that the current codes provide a structure for ethical practice that is more useful for young or new practitioners. In small, isolated communities confidentiality is a major concern, with practitioners unable to express their cases with anyone except those directly involved. This situation was described as fear-based because some people could be trusted and others could not. One participant explained: Holy smokes, I understand the confidentiality piece, absolutely but the system really stinks sometimes because it’s not that I’m breaching confidentiality. I don’t want to breach; I want to work as a team . . .. (10111401-2)

It is common for northern practitioners working in isolation to have no one to consult with so the participants stressed the importance for all helpers to be trained in ethical standards of practice.

Cultural context The participants in this study identified a number of elements that are central to culturally appropriate practice in the North. The term ‘‘cultural sensitivity’’ was used to define an approach which incorporates awareness and acceptance of cultural differences as well as openness to learning about Aboriginal cultures and

each client’s cultural context. Awareness of an Aboriginal orientation suggested by participants is having some knowledge about the beliefs and values of Aboriginal cultures and understanding the diversity of these beliefs and values. Another vital component shared by participants was the need to understand the transmission, depth and prevalence of the historical trauma that plagues Aboriginal peoples. The idea that the trauma is prevalent and pervasive was discussed throughout the interviews. As well, participants suggested that understanding context involved recognizing that all client issues are connected in some way to the loss of cultural identity and language.

Sustaining northern practice The theme of connection and relationships highlights sustaining factors of reciprocity, connection and community. The participants repeatedly discussed meaningful relationships with colleagues, clients and community members. Some of the participants described feeling very supported by their colleagues, with peers serving as practitioners’ main supporters. The passion and commitment for the work was driven by the connections with clients and community. One practitioner described it as, ‘‘the love you have for a feeling, a place, people’’ (10072202). The practitioners were passionate about advocacy at all levels including advocating for clients and community, for their profession, and for changes in systems. One participant explained: The advocacy piece is huge because when you’re so concerned with the level of racism, discrimination, oppression, poverty then you have to do something. And that’s where it went to you know that’s where it went to (10072202).

Resilience was also identified by long-term practitioners who have continued to do the work for many years while colleagues have quit, changed professions, or gone on education or sick leave. For these practitioners, living in the North was described as providing opportunities to meet interesting people and work with diverse cultures.

Conclusion The skills and wisdom held by the participating practitioners is evidence of the requirements for doing this extreme form of mental health support in some of the most challenging conditions in North America. Mental health and wellness support in isolated communities with high professional visibility and limited support demandspecific qualities from the people who provide such support. Research and community development focused on mental health may help to alleviate the workload of such practitioners.


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Future research In the beginning of the qualitative interviews, we had to redefine how we used the term ‘‘mental health’’ as informal helpers appeared to see the term in a more narrow Axis II interpretation, so we added the term ‘‘wellness’’. In future research, we will define mental health in the broadest terms with participants. We wonder if the stigma of mental health issues may be tied to this narrow definition of the term in communities and whether workshops on broad mental health issues and the effects of complex trauma would be helpful. Future research into Aboriginal views and strategies on improving mental health within northern communities would be extremely beneficial. More in-depth explorations of the situation of a mental health insider and informal supporters would also potentially improve services. In our research we will work to be more specific in defining who informal practitioners might be and what type of support they provide.

Limitations In conjunction with redefining the term ‘‘mental health’’, we realize that we were not as successful in accessing those practitioners who provide informal mental health support, particularly Aboriginal informal mental health supporters. This type of recruitment would involve the use of community connections and the balancing of dual relationships. We also realize that many informal practitioners are doing essential mental health support but may not define their work in this way, related to a more narrow definition of mental health.

Research reflection Northern mental health and wellness practice could be viewed as living in a land of uncertainty where individuals, ethical practice and communities were evolving as issues of practice and culture were worked out in northern settings. The external components of geography, community, resources and funding all appear to contribute to the internal struggles of practitioners. Many of the practitioners who participated in this study have found ways to overcome the biggest challenges of northern practice, yet the limitations of small populations and lack of resources in small communities to adequately address mental health support were identified as existing. With issues contributing to lack of mental health and wellness defined by participants as endemic and deep into the core of many communities, communication between practitioners may be a positive step in defining the commonalities and the differences found in various northern settings and in sharing strategies and local knowledge that may have relevance to other communities and practitioners. Empowering communities by building

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community capacity to educate, supervise and support formal and informal mental health workers is a long-term goal of many of the participants and the authors.

Acknowledgements The authors and research team express gratitude to all participants who shared their wealth of wisdom and insight in the interviews. They thank Willow Hobson, Jodie Petruzellus and Nicole Robinson for their work on the interview analysis. The authors and research team also extend appreciation to the Social Sciences and Humanities Research Council of Canada (SSHRC) for funding that made this research possible.


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Energy drink use, problem drinking and drinking motives in a diverse sample of Alaskan college students Monica C. Skewes1,2*, Christopher R. DeCou3 and Vivian M. Gonzalez4 1

Department of Psychology, University of Alaska Fairbanks, Fairbanks, AK, USA; 2Center for Alaska Native Health Research, University of Alaska Fairbanks, Fairbanks, AK, USA; 3Department of Psychology, Idaho State University, Pocatello, ID, USA; 4Department of Psychology, University of Alaska Anchorage, Anchorage, AK, USA

Background. Recent research has identified the use of caffeinated energy drinks as a common, potentially risky behavior among college students that is linked to alcohol misuse and consequences. Research also suggests that energy drink consumption is related to other risky behaviors such as tobacco use, marijuana use and risky sexual activity. Objective. This research sought to examine the associations between frequency of energy drink consumption and problematic alcohol use, alcohol-related consequences, symptoms of alcohol dependence and drinking motives in an ethnically diverse sample of college students in Alaska. We also sought to examine whether ethnic group moderated these associations in the present sample of White, Alaska Native/American Indian and other ethnic minority college students. Design. A paper-and-pencil self-report questionnaire was completed by a sample of 298 college students. Analysis of covariance (ANCOVA) was used to examine the effects of energy drink use, ethnic group and energy drink by ethnic group interactions on alcohol outcomes after controlling for variance attributed to gender, age and frequency of binge drinking. Results. Greater energy drink consumption was significantly associated with greater hazardous drinking, alcohol consequences, alcohol dependence symptoms, drinking for enhancement motives and drinking to cope. There were no main effects of ethnic group, and there were no significant energy drink by ethnic group interactions. Conclusion. These findings replicate those of other studies examining the associations between energy drink use and alcohol problems, but contrary to previous research we did not find ethnic minority status to be protective. It is possible that energy drink consumption may serve as a marker for other health risk behaviors among students of various ethnic groups. Keywords: caffeine; alcohol problems; drinking to cope

he use of caffeinated energy drinks worldwide has grown substantially in recent years and has raised important questions concerning the potential health impacts of this growing trend (1). Recent investigations have identified the use of energy drinks as a common and potentially risky behavior among college students (25). Although the problematic use of energy drinks is not limited exclusively to college students (6), the college setting and lifestyle in combination with targeted marketing of energy drinks towards adolescents and emerging adults may contribute to high rates of energy drink use among students. Associations have been noted between the consumption of energy drinks and health risk behaviors among college students (1). Recent

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scholarship has identified numerous examples of such associations, including increased alcohol consumption, alcohol-related consequences, sexual risk-taking, tobacco use and the use of other substances (2,4,79). Several studies have noted the association between energy drink and alcohol misuse among college students (2,4,7). This association has been particularly salient in research that specifically measured consumption of alcohol mixed with energy drinks (AMED; 2,9). A recent study found that college students consuming AMED reported increased alcohol consumption compared to other drinking episodes during which they had not mixed alcohol with energy drinks, after controlling for respondents’ selfreported risk-taking propensity (2). A recent experiment


Energy drinks and alcohol

found increased self-reported desire to consume alcohol among participants randomly assigned to drink AMED in comparison to alcohol-only, energy drink-only and placebo conditions (10). These findings are congruent with previous research highlighting the association between energy drink use and alcohol consequences. Specifically, O’Brien et al. (7) conducted a web-based survey of college students (N 4,271), and observed substantially greater rates of problem drinking behaviors (e.g. drunkenness, heavy episodic drinking) in AMED users compared to students who did not combine alcohol with energy drinks (7). These findings, among others (e.g. 9,11,12), demonstrate the problematic consequences of combining alcohol and energy drinks, and may indicate a moderating effect of energy drink use on the relationship between alcohol consumption and alcohol-related problems among college students. However, research focused specifically on AMED does not address the broader associations that may exist between overall energy drink consumption (i.e. not mixed with alcohol as a cocktail) and other health risk behaviors and mental health variables. Other recent research evaluated data from a longitudinal study of university undergraduates and found that the association between energy drinks and alcohol consumption appears to be related to specific patterns (i.e. low-dose or high-dose) of energy drink consumption (13). The authors found that energy drink consumption was predictive of alcohol consumption for those students engaging in daily or weekly consumption of energy drinks. Conversely, no such association was observed among students who reported ‘‘low-dose’’ consumption of energy drinks, even after controlling for family history of alcohol problems and typical alcohol consumption (13). As distinguished from investigations that have explored AMED specifically, Miller identified an association between overall frequency of energy drink consumption and problem drinking behaviors among college students (4). Furthermore, Miller observed associations between the frequency of energy drink use and the use of tobacco, marijuana, non-medical use of prescription medications and sexual risk-taking (4). However, the use of energy drinks did not predict risk-taking as measured by participation in extreme sports. In this way it seems that the frequency of energy drink consumption may not predict all types of risk-taking, but rather explains certain health risk behaviors, like binge drinking, that are normative within the context of university communities. Additionally, Miller found that race moderated the relationship between energy drinks and substance use; that is, the associations between energy drinks and substance use observed among White college students were not observed among African American students (14). Similarly, O’Brien et al. observed variation in university students’ use of AMED, with White students evidencing greater likelihood

of AMED use (7). These findings raise the question of whether ethnicity may serve as a protective factor for negative outcomes related to energy drink use among other ethnic minorities. The present study analysed data from a survey of 298 college students at a minority-serving 4-year public university in Alaska. The survey included various measures of health-related behaviors including energy drink consumption, alcohol involvement, other substance use and mental health variables. This paper specifically addresses the relationship between self-reported weekly energy drink consumption and measures of hazardous drinking, alcohol consequences, symptoms of alcohol dependence and drinking motives. Although there is a growing literature concerning the health effects of energy drinks, this paper seeks to contribute to the existing literature in the following ways: (a) replicate findings of previous research concerning the relationship between energy drinks and problematic alcohol use in an ethnically diverse sample of Alaskan university students; (b) examine the associations between energy drink consumption and drinking motives; and (c) examine the effect of ethnic group on these associations in our sample of White, Alaska Native/American Indian and other ethnic minority college students.

Method Participants Participants included 298 undergraduate college students (63.4% female) enrolled at a public university in the circumpolar north. Ages ranged from 18 to 52 (M 23.03, SD 6.53). The majority of students were emerging adults (80.1% were between 18 and 25 years of age). Freshmen were most represented in our sample (n 125, 41.9%), with the remainder of the sample evenly distributed between sophomores, juniors and seniors. Regarding ethnicity, 68.4% (n 201) students self-identified as White, 17.7% (n52) identified as Alaska Native or American Indian, and 13.9% (n45) were other ethnic minorities. Participants in the ‘‘other’’ category included African American, Latino/a and Asian American students. The characteristics of the current sample were reasonably aligned with population characteristics, as 59% of the university’s student body is female, the median age is 25, and approximately 18% of the student body is Alaska Native/American Indian. Measures Energy drink use Energy drink consumption was measured using a single item instructing participants to indicate the number of energy drinks they consume per week, on average. Five categories ranging from 0 (less than one) to 5 (15 or more) were provided for respondents. Examples of energy


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drinks were provided so as not to be confused with coffee or other caffeinated beverages. Energy drinks consumed per average week were used as an independent variable in the analyses.

Hazardous drinking The Alcohol Use Disorders Identification Test (AUDIT; 15) is a 10-item self-report instrument developed by the World Health Organization as a screening tool for hazardous drinking. Items are scored from 0 to 4 and responses are summed to yield a total score, with higher values indicating a greater likelihood of having an alcohol use disorder. AUDIT scores ]8 indicate the presence of ‘‘hazardous drinking’’ (16). One item asked respondents to indicate the frequency with which they consume 6 or more standard drinks on 1 occasion, rated from 0 (never) to 4 (4 or more times per week). As binge drinking is currently defined as 4 or more standard drinks in 1 sitting for a woman and 5 or more standard drinks for a man (17), this item provides a conservative estimate of binge drinking for both women and men. Frequency of binge drinking was included as a covariate in the analyses. Alcohol problems The Young Adult Alcohol Consequences Questionnaire (YAACQ; 18) is a 48-item self-report inventory of problems commonly associated with alcohol use among college students. Items are rated as: present (1) or absent (0) within the past 12 months. Responses are summed to yield a total score, with higher scores indicating greater alcohol problems. Alcohol dependence symptoms The Short Alcohol Dependence Data questionnaire (SADD; 19) is a 15-item measure of current symptoms of alcohol dependence such as excessive thinking about drinking or perceived inability to control one’s drinking. Items are scored from 0 (never) to 3 (nearly always) and are summed to yield a total score, with higher scores indicating greater severity of dependence symptoms. Drinking motives The Drinking Motives Questionnaire-Revised (DMQ-R; 20) consists of four 5-item subscales assessing the motives for drinking, including drinking for social reasons (e.g. to bond with others), drinking to cope with negative affect (e.g. to forget one’s problems), drinking for enhancement reasons (e.g. to increase enjoyment or have fun) and drinking for conformity reasons (e.g. drinking to fit in). Questions ask respondents to indicate how frequently they drink in response to these motives on a scale of 1 (almost never) to 4 (almost always). The possible range for each subscale (Social, Coping, Enhancement, Conformity) is 520, with higher scores indicating greater self-reported drinking in response to that motive.

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Demographics Participants were instructed to indicate their age, gender and ethnicity. Participants who self-reported American Indian or Alaska Native heritage were classified as ‘‘Native.’’ The remaining participants were classified by self-report as ‘‘White’’ or ‘‘Other ethnic minority.’’ The ‘‘Other’’ group included an approximately even distribution of African American, Latino/a and Asian American participants. Procedure Participants were recruited via in-class announcements and received extra course credit for their time. They gave informed consent and completed packets of paper-andpencil measures in small groups. Each participant was given a manila envelope with the survey and instructed to place the completed questionnaire into the envelope and then to place the envelope into a large box filled with other similar envelopes. This procedure was intended to enhance participants’ confidence that their responses would not be linked back to them or identifiable in any way, thereby improving validity of self-reports. The university’s Institutional Review Board approved all methods and materials. Analyses Descriptive statistics and bivariate correlations were calculated for all study variables. Then, a series of analyses of covariance (ANCOVAs) were conducted to examine the effects of ethnic group and energy drink consumption on alcohol outcomes while controlling for variance attributed to age, gender and frequency of binge drinking. The independent variables in all analyses were ethnic group and energy drink consumption. The covariates were age, gender and frequency of binge drinking. The dependent variables were AUDIT scores, YAACQ scores, SADD scores and all DMQ subscale scores. Main effects of ethnic group and energy drink consumption were examined and are reported here. Interactions between ethnicity and energy drink use were examined, but because there were no significant interactions, only main effects will be discussed.

Results Descriptives and correlations In the present sample, 39.2% of participants (n124) reported consuming energy drinks at least once per week, with the number of energy drinks per week ranging from 0 to 15. The majority of the sample reported consuming alcohol in the previous 30 days (66.3%; n191), and the mean number of standard drinks consumed in the prior month was 12.61 (SD 19.11, range088). Total AUDIT scores ranged from 0 to 25 (M 5.23, SD4.98) with 31.9% of women and 18.8% of men meeting the criteria for hazardous drinking. Frequency of consuming



6 standard drinks on 1 occasion ranged from 0 to 16 days per month (M1.16, SD2.91). Total YAACQ ranged from 0 to 48 (M8.83, SD 10.57) and SADD scores ranged from 0 to 22 (M3.13, SD 4.40). The full range (020) for all DMQ subscales was present, with the highest scores reported for social motives (M11.18, SD4.65), followed by enhancement motives (M10.09, SD4.45), coping motives (M 8.87, SD4.01) and conformity motives (M6.65, SD 2.71). Energy drink consumption was significantly negatively associated with age (r 16, p B.01), but was not associated with gender. There were no significant differences in energy drink use by ethnic group. Significant associations were found between energy drink consumption and all dependent variables with the exception of the DMQ-conformity subscale scores (see Table I for bivariate correlations between energy drink use and all dependent variables).

covariate was significant for both. Energy drink use was a significant predictor of DMQ-Coping scores (F(4, 249)5.04, p .001, partial h2 .08), but neither ethnic group nor the energy drink by ethnic group interaction were significant. Energy drink use also significantly predicted DMQ-Enhancement scores (F(4, 248) 4.60, p .001, partial h2 .07).

Discussion This research sought to replicate the previously reported associations between energy drink use, problem drinking and alcohol consequences in an ethnically diverse sample of Alaskan college students. Further, we explored energy drink use in relation to alcohol dependence symptoms and drinking motives. Because of Miller’s finding that race moderated the association between energy drink consumption and alcohol outcomes in a sample of White and African American college students (4), we examined energy drink by ethnic group interactions in the present sample. Contrary to Miller’s research, we found no moderating effect of ethnicity, nor did we find a main effect of ethnic group for any of the dependent variables examined. In the present sample, the associations between energy drink use and alcohol outcomes were equivalent for White, Alaska Native/American Indian and other ethnic minority Alaskan students. There were several significant and moderate correlations between variables. Students who reported greater energy drink consumption also reported greater frequency of binge drinking, greater drinking to cope, greater alcohol-related problems, greater alcohol dependence symptoms, and were at greater risk of having an alcohol use disorder. Controlling for age, gender and frequency of binge drinking, energy drink use significantly predicted scores on measures of problem drinking, alcohol consequences, dependence symptoms, enhancement motives and coping motives. Of particular interest was the association between energy drink use and coping drinking motives. Drinking to cope is a particularly problematic motive that has been shown to predict greater alcohol use and greater severity of alcohol

Analyses of covariance See Table II for the marginal means of the dependent variables examined in the ANCOVAs by ethnic group. Controlling for age, gender and frequency of binge drinking, energy drink use was a significant predictor of total AUDIT scores (F(4, 257)6.00, p B.001, partial h2 .09) but there were no significant differences in AUDIT scores between ethnic groups, nor was there a significant energy drink by ethnic group interaction. Similarly, in the ANCOVA examining YAACQ scores, energy drink use was a significant predictor (F(4, 257) 2.66, p B.05, partial h2 .04) but ethnic group was not. There also was no significant interaction. This pattern of findings was observed for SADD scores also, with energy drink use emerging as a significant predictor (F(4, 249) 3.75, p B.01, partial h2 .06), while ethnic group and the energy drink by ethnic group interaction were not significant. ANCOVAs also were conducted to examine each drinking motive as measured by the DMQ-R, controlling for age, gender and binge drinking. None of the independent variables significantly predicted DMQ-Social or DMQ-Conformity scores, although the binge drinking

Table I. Intercorrelations of dependent variables and energy drink consumption (N298) Variables

1

2

3

4

5

6

7

8

*

1. Hazardous drinking 2. Alcohol consequences

.74***

*

3. Dependence symptoms

.79***

.75***

*

4. Motives social

.62***

.52***

.54***

*

5. Motives coping 6. Motives enhancement

.64*** .66***

.63*** .55***

.65*** .63***

.76*** .79***

* .74***

*

7. Motives conformity

.24***

.31***

.25***

.52***

.47***

.35***

*

8. Energy drinks per week

.25***

.15*

.17**

.18**

.24***

.28***

.02

*

Note: *pB.05. **p B.01. ***p B.001. Citation: Int J Circumpolar Health 2013, 72: 21204 - http://dx.doi.org/10.3402/ijch.v72i0.21204

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Table II. Adjusted (marginal) means and standard deviations for 3 ethnic groups and 7 dependent variables (N 298) Variables 1. Hazardous drinking

White

Alaska Native

Other ethnic minority

6.42 (.44)

5.39 (.77)

8.95 (1.10)

2. Alcohol consequences

10.68 (1.18)

11.44 (2.12)

12.41 (2.94)

3. Dependence symptoms 4. Motives social

3.77 (.47) 12.43 (.56)

3.81 (.83) 11.37 (1.00)

6.58 (1.17) 12.89 (1.39)

5. Motives coping

10.03 (.47)

9.71 (.85)

11.79 (1.18)

6. Motives enhancement

11.49 (.50)

10.93 (.91)

13.44 (1.26)

6.23 (.34)

8.35 (.79)

6.48 (.87)

7. Motives conformity

problems and consequences than drinking for other motives (21,22). Beyond its influence on alcohol use itself, drinking to cope may affect decision making regarding when and where to drink, thereby increasing alcohol consequences above and beyond its direct effect on alcohol consumption (23). These findings, along with those from previous research, raise the question: why does energy drink use predict alcohol problems after controlling for alcohol consumption? We do not posit that the link is causal. However, we do hypothesize that intrapersonal factors such as personality variables (e.g. sensation seeking) may account for substance use behavior in general, including energy drink use. Indeed, other research has found greater sensation seeking among energy drink users than non-energy drink users (8,24). Further research is needed to understand the nature of these relationships particularly if energy drink use may serve as a marker for other problem behaviors and symptoms. In addition to our hypothesis regarding individual difference variables explaining the association between energy drinks and alcohol, we also think it is possible that some students may be self-medicating for untreated symptoms of Attention Deficit Hyperactivity Disorder (ADHD). Stimulants are used to treat ADHD symptoms, and caffeine may improve concentration and focus among people with ADHD. Although some research has examined motives for consuming AMED (e.g. 11) future research should examine motives for energy drink use independent of AMED as well as energy drink outcome expectancies among college students. A promising measure of caffeine expectancies has recently been developed (i.e. Caffeine Expectancy Questionnaire; 25) and would yield important information for understanding energy drink motives in future research.

Limitations Limitations of this research include the overrepresentation of women and the underrepresentation of Alaska Native/American Indian and other ethnic minority students in the current sample. It is entirely possible that ethnicity may serve as a protective factor for minority

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students but that the small percentages of non-White students in this sample did not allow us to detect significant main effects or interactions. It is possible that African American culture is protective (4), but because African American students were grouped with other ethnic minorities the protective effects were obscured. Unfortunately, we did not have the statistical power to examine African American students separately from other ethnic minorities. Future research should use purposive sampling to replicate Miller’s finding that energy drink use was not associated with problematic drinking and alcohol consequences among African American students (4). Other limitations include the cross-sectional design of this research, which does not allow for examination of causal pathways. Moreover, we neglected to assess whether energy drinks were being consumed with alcohol in AMED or without alcohol, which may have facilitated deeper understanding of the link between energy drink use and alcohol consumption. Finally, we did not assess sensation seeking, an important personality variable that has been shown to differ between energy drink users and non-users (8,24). Nevertheless, this research contributes to the extant literature on this topic by examining the effect of overall energy drink use on various criterion variables related to problematic alcohol use, including the important alcohol motive of drinking to cope. This research also is unique in its focus on a college student sample in the circumpolar north with high rates of alcohol use disorders. As research examining the effects of energy drink use on risky behaviors and health outcomes accumulates, we will be able to better understand how to use knowledge about college students’ energy drink consumption to identify students at risk for serious problems.

Conflict of interest and funding Research reported in this publication was supported by the National Institute of General Medical Sciences of the National Institutes of Health under award number P30GM103325. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.



References 1. Reissig CJ, Strain EC, Griffiths RR. Caffeinated energy drinks*a growing problem. Drug Alcohol Depend. 2009; 99:110. 2. Brache K, Stockwell T. Drinking patterns and risk behaviors associated with combined alcohol and energy drink consumption in college drinkers. Addict Behav. 2011;36:113340. 3. Marczinksi CA. Alcohol mixed with energy drinks: consumption patterns and motivations for use in U.S. college students. Int J Environ Res Public Health. 2011;8:323245. 4. Miller KE. Energy drinks, race, and problem behaviors among college students. J Adolesc Health. 2008;43:4907. 5. Oteri A, Salvo F, Caputi AP, Calapai G. Intake of energy drinks in association with alcoholic beverages in a cohort of students of the school of medicine of the University of Messina. Alcohol Clin Exp Res. 2007;31:167780. 6. Berger LK, Fendrich M, Chen H, Arria AM, Cisler RA. Sociodemographic correlates of energy drink consumption with and without alcohol: results of a community survey. Addict Behav. 2011;36:5169. 7. O’Brien MC, McCoy TP, Rhodes SD, Wagoner A, Wolfson M. Caffeinated cocktails: energy drink consumption, high-risk drinking, and alcohol-related consequences among college students. Acad Emerg Med. 2008;15:45360. 8. Arria AM, Caldeira KM, Kasperski SJ, O’Grady KE, Vincent KB, Griffiths RR, et al. Increased alcohol consumption, nonmedical prescription drug use, and illicit drug use are associated with energy drink consumption among college students. J Addict Med. 2010;4:7480. 9. Thombs DL, O’Mara RJ, Tsukamoto M, Rossheim ME, Weiler RM, Merves ML, et al. Event-level analysis of energy drink consumption and alcohol intoxication in bar patrons. Addict Behav. 2010;35:32530. 10. Marczinski CA, Filmore MT, Henges AL, Ramsey MA, Young CR. Mixing an energy drink with an alcoholic beverage increases motivation for more alcohol in college students. Alcohol Clin Exp Res. 2013;37:27683. 11. Marczinski CA, Fillmore MT, Bardgett ME, Howard MA. Effects of energy drinks mixed with alcohol on behavioral control: risks for college students consuming trendy cocktails. Alcohol Clin Exp Res. 2011;35:128292. 12. Price SR, Hilchey CA, Darredeau C, Fulton HG, Barrett SP. Energy drink co-administration is associated with increased reported alcohol ingestion. Drug Alcohol Rev. 2010;29:3313. 13. Arria AM, Caldeira KM, Kasperski SJ, Vincent KB, Griffiths RR, O’Grady KE. Energy drink consumption and increased risk for alcohol dependence. Alcohol Clin Exp Res. 2011;35:36575.

14. Miller KE. Wired: energy drinks, jock identity, masculine norms, and risk taking. J Am Coll Health. 2008;56:4819. 15. Saunders JB, Aasland OG, Babor TF, De La Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption-II. Addiction. 1993;88:791804. 16. Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. The Alcohol Use Disorders Identification Test: guidelines for use in primary care. 2nd ed. Geneva, Switzerland: Department of Mental Health and Substance Dependence, World Health Organization; 2001. 17. Wechsler H, Nelson TF. Binge drinking and the American college students: what’s five drinks? Psychol Addict Behav. 2001;15:28791. 18. Read JP, Kahler CW, Strong DR, Colder CR. Development and preliminary validation of the young adult alcohol consequences questionnaire. J Stud Alcohol. 2006;67:16977. 19. Raistrick DS, Dunbar G, Davidson RJ. Development of a questionnaire to measure alcohol dependence. Br J Addict. 1983;78:8995. 20. Cooper ML. Motivations for alcohol use among adolescents: development and validation of a four-factor model. Psychol Assess. 1994;6:11728. 21. Cooper ML, Frone MR, Russel M, Mudar P. Drinking to regulate positive and negative emotions: a motivational model of alcohol use. J Per Soc Psychol. 1995;69:9901005. 22. Park CL, Levenson MR. Drinking to cope among college students: prevalence, problems, and coping processes. J Stud Alcohol. 2002;63:48697. 23. Simons JS, Gaher RM, Correia CJ, Hansen CL, Christopher MS. An affective-motivational model of marijuana and alcohol problems among college students. Psychol Addict Behav. 2005;19:32634. 24. Miller KE, Quigley BM. Energy drink use and substance abuse among musicians. J Caffeine Res. 2011;1:6773. 25. Huntley ED, Juliano LM. Caffeine Expectancy Questionnaire (CaffEQ): construction, psychometric properties, and associations with caffeine use, caffeine dependence, and other related variables. Psychol Assess. 2012;24:592607. *Monica C. Skewes Center for Alaska Native Health Research University of Alaska Fairbanks 902 N. Koyukuk, Room 311 Fairbanks, AK 99775-7000 USA Email: [email protected]


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Resituating the ethical gaze: government morality and the local worlds of impoverished Indigenous women Caroline L. Tait* Department of Psychiatry, University of Saskatchewan, Saskatoon, Canada

Background. Over generations, government policies have impacted upon the lives of Indigenous peoples of Canada in unique and often devastating ways. In this context, Indigenous women who struggle with poverty, mental illness, trauma and substance abuse are among the most vulnerable, as are Indigenous children involved in child welfare systems. Objective. By examining the life history of Wanda, a First Nations woman, this article examines the intergenerational role that government policies play in the lives of impoverished Indigenous women and their families. Questions of moral governance and responsibility and the need for ethical policies are raised. Design. The life narrative presented in this article is part of a larger qualitative research programme that has collected over 100 life histories of Indigenous women with addictions and who have involvement with the child welfare system, as children or adults. Wanda’s life story exemplifies the impact of government policies that is characteristic of vulnerable Indigenous women and draws attention to the lack of ethical standards in government policymaking in child welfare, public health and mental health/addictions. Results. The path to recovery for Canadian Indigenous women in need of treatment for co-occurring mental disorders and substance addiction is too frequently characterized by an inadequate and ever shifting continuum of care. For those who feel intimidated, suspicious or have simply given up on seeking supports, a profound invisibility or forgetting of their struggle exists in areas of government policy and programming provision. Living outside the scope of mental health and addiction priorities, they become visible to the human service sector only if they become pregnant, their parenting draws the attention of child and family services (CFS), they need emergency health care, or are in trouble with the law. The intergenerational cycle of substance abuse, mental illness and poverty is commonly associated with child welfare involvement, specifically practices that place the health and well-being of Indigenous children at risk. In order to break this cycle, close attention to implementation of ethically based policies and best practice interventions is required. Conclusions. From an ethical policy perspective, the focus of government policies and the practices they generate must be first and foremost to ensure that individuals, families and groups are not left worse off than prior to a government policy impacting upon their life. Furthermore, the impact of living a life determined by multiple government policies should not be a story of individual and family devastation, and government policies should not be the most significant determinant of health for any group of people. Keywords: ethical policy; First Nations; child welfare; addictions; mental illness; government policy

he path to recovery for Canadian Indigenous women in need of treatment for co-occurring mental disorders and substance addiction is too frequently characterized by an inadequate and ever shifting continuum of care (1,2). For those who feel intimidated, suspicious or have simply given up on seeking supports, a profound invisibility or forgetting of their struggle exists in areas of government policy and programming provision (35). Living outside the scope of mental health and addiction priorities, they become visible to the human service sector only if they become pregnant,

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their parenting draws the attention of child and family services (CFS), they need emergency health care, or are in trouble with the law (5,6). Throughout Canada, elevated morbidity and mortality rates among impoverished Indigenous women are unacceptably high (7,8). For decades, rates of substance abuse and mental illness among this subgroup have constituted a population-based mental health crisis. However, despite a substantial body of research illustrating the enormous human, social and economic cost associated with the crisis (1,5,9,10), comprehensive women-centred and


Resituating the ethical gaze

culturally safe interventions are limited and in some regions non-existent. Anthropologist Dara Culhane argues that a ‘‘neoliberal mode of governance selectively marginalizes and/ or erases entire categories of people through strategies of representation’’ (1, p. 595). For example, metaphors of ‘‘investing,’’ ‘‘high-performance,’’ ‘‘accountability’’ and the adopting of ‘‘quality improvement’’ approaches developed in the manufacturing sector dominates contemporary approaches to health care and social welfare reform (11,12). However, emphasizing system ‘‘efficiencies’’ while operating within 4-year political cycles, challenge managers to implement comprehensive ‘‘evidence-based’’ interventions that require longer term applications and the support of multiple government ministries. Coordination between government ministries responsible for the human service sector is near impossible within the existing bureaucracies and represents a significant stumbling block to addressing poverty and other complex social problems. Added to this are jurisdictional lines that divide up governments’ responsibility for Indigenous peoples along federal and provincial/territorial lines, or across government ministries. Creative and innovative ‘‘evidencebased’’ initiatives become mired in bureaucratic inertia, jurisdictional disputes and short-term political mandates. As a result, the application of ‘‘best practices’’ and policy recommendations are more often watered down to actions that support the limitations of the bureaucracy rather than implemented to evidence-based standards (2,13). In the current neo-liberal context, individuals labelled as living ‘‘high risk’’ or ‘‘unproductive’’ lifestyles are viewed as poor investments with limited positive return to the broader society. However, the needs of this group are complex and require intense (often costly and long-term) interventions to improve their lives (14,15). Keeping individuals on the margins of care through policies that create, rather than dismantle, barriers and gaps to access support services not only saves on immediate (but not necessarily lifetime) health care and social welfare spending, it also sends a message that the government’s primary concern is with the ‘‘worthy’’ and not the ‘‘undeserving’’ or ‘‘non-contributing.’’ This message has strong societal support in a country where prevailing attitudes see impoverished Indigenous women as ‘‘liabilities’’ (e.g. they give birth to too many babies that they cannot care for; are habitual welfare recipients) and never as ‘‘assets’’ (e.g. educated, employed taxpayers) to Canadian society. This article reconsiders the complexities that shape the lived experiences of Indigenous women who simultaneously struggle with poverty, violence, trauma and addictions. The life narrative of Wanda, a First Nations woman, captures the intersecting factors that shape the lives of women who are essentially invisible and unwanted within Canadian society. Wanda’s life has been shaped by government policies: from residential school policies

that debilitated her parents; to CFS policies that permitted her to be moved from foster home to foster home while failing to safeguard against abuse; to policies that funded short- but not long-term residential treatment for her addiction. As Wanda’s life story reveals, governments intervened in her troubled life at times of ‘‘crisis’’ and in doing so very narrowly defined risk, the ethical management of it, and excluded other mitigating factors. The enormous personal toll for Wanda was lost in technocratic government responses (or non-responses) that were marked by institutionalized race, sex, and class discrimination, and by her own devalued self-worth and diminished moral right to societal support. Drawing attention to societal inequities, Wanda’s narrative raises questions of moral governance and responsibility: ‘‘Are federal and provincial governments responsible for the life of pain and suffering experienced by Wanda, if she is not?’’; ‘‘Where are the ethical checks and balances within government policies that take seriously beneficence and nonmaleficence for all people?’’; and, ‘‘If the government failed to safeguard against life-long harm to Wanda when she was a foster child, does it not have a moral obligation to ensure that as an adult she has enhanced supports to address the trauma she endured while in the State’s care?’’

Wanda When I met Wanda she was living in a poverty-stricken neighbourhood in Saskatoon.1 She was among a subgroup of women described by outreach workers as ‘‘falling through the cracks’’ of health and welfare systems. At the age of 34, Wanda was confined to a wheelchair after being hit by a car. Her health was rapidly deteriorating and she was living with severe chronic pain. While physiotherapy initially helped, she stopped attending 5 months into her treatment because she felt judged by the therapists about her substance abuse. Wanda’s life is full of multiple challenges, including getting around in her non-electric wheelchair, living on a small disability allowance, and staying safe on the streets. She states: It’s a battle. I try to stop [using substances] but I sit down sometimes and everything just builds up inside me. All my problems are coming and I just do that to forget. As a young child Wanda lived on a northern reserve. Both her parents had attended residential schools, returning to their reserve as young troubled teenagers. Wanda remembers never having food in their house, her parents always drinking and the children often being left alone. When she was 4, CFS apprehended Wanda and her siblings, placing them with different families. In foster care, Wanda experienced multiple placements in homes 1 To protect Wanda’s confidentiality, the name used is a pseudonym, as are the locations. Wanda’s life narrative is from a larger study and exemplifies the life narratives that I have collected over the past 18 years from Indigenous women who have lost their children to CFS.


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run by non-Indigenous foster parents. While most of the homes were supportive, in 2 of them she was repeatedly sexually and physically abused by the foster father and in both cases the abuse went undetected by CFS. The frequent moves of homes and schools left Wanda feeling isolated and alone, unable to fight back against the abuse. Wanda was 14 when she started abusing alcohol with other foster children. She used throughout her adolescence and into adulthood, with periodic breaks. While it must have been obvious to some of the adults in her life that she was struggling, Wanda was never offered therapeutic or other supports by CFS. Wanda ‘‘aged out’’ of foster care with a growing substance abuse problem, untreated psychological trauma, and no connection to her biological family, her reserve, or to any of her foster families. At the age of 18, Wanda became pregnant. She was young, alone, a street worker, and getting high every day. As with many pregnant girls in similar situations, Wanda avoided prenatal care, fearing judgement because of her lifestyle. With no support from the father of her baby, Wanda spent the first months of her pregnancy drinking, drugging and ‘‘working the streets.’’ Fortunately, a social worker became aware of her pregnancy and helped her to enter residential addiction treatment. While the treatment centre gave Wanda stability, it was a 30-day programme with limited aftercare or transitional supports. Once she left the treatment centre, Wanda quickly fell back into the same lifestyle and started using again. The gains that she made in treatment were quickly lost and her relapse fuelled feelings of low self-worth, guilt and shame. With the birth of her daughter, Wanda tried to parent, however she struggled as a young mother with no supports. CFS eventually stepped in and apprehended her daughter triggering an escalation of Wanda’s substance abuse (no supports for her grief and loss) and reliance on prostitution (reduction of social welfare benefits). Within a short period, Wanda’s daughter was placed for adoption. After a few hard years, Wanda married and moved to Edmonton with her husband. This was a relatively stable time even though they struggled financially and were both using heavily. They had 2 daughters and Wanda attended an outreach programme during both pregnancies where she felt genuinely supported. Shortly after the birth of their second child, Wanda separated from her husband because of his infidelity. After her separation, she managed to parent her children and keep her substance abuse under control. However, her substance abuse escalated again when she began a new relationship: Well I did [quit using substances] when my girls were small and living with me. Well, I did it with them [used substances when pregnant] but then after that I didn’t do it for about two or three years. And then I was living with this abusive man. He beat me up all

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the time and I started doing everything again. Then I phoned my sister and she came and got me. I came to Saskatoon and I started using and I lost them [her daughters to CFS].

The move to Saskatoon, while helping Wanda to get away from an abusive relationship, marginalized her further. She began working the streets and her substance abuse escalated. CFS apprehended Wanda’s daughters and after she failed to complete addiction treatment, they moved the girls to Edmonton to live with their father. Alone and without her children, she moved into a run-down rooming house, increased her substance use and worked the streets until the birth of her son. While different supports were offered to her, including referral to addiction treatment and prenatal care, Wanda’s depression was so severe that it prevented her from pursuing these supports. At the age of 30, Wanda consented to a tubal ligation immediately following the birth of her son. The nurses told her that her baby was born with debilitating health problems resulting from her substance abuse. Out of guilt and shame Wanda consented to a tubal ligation, her son was taken by CFS, and she left the hospital without a referral to either addiction treatment or grief counselling: I got my tubes tied ‘cause I didn’t want to put more pain on my kids. I really punished my boy a lot. I told them to do it. When I seen what I did to my boy, I said, ‘‘Tie my tubes ‘cause I caused him lots of pain,’’ . . . they didn’t even let me hold him . . . they just took him away . . .. I went to court but I didn’t get him back. He can think, but he’s got to be on medication ‘cause I did lots with him . . . with my boy I had no support ‘cause I left my husband. I was pregnant with him, I was working on the street with him. I was using drugs.

Once her son was apprehended and the tubal ligation completed, Wanda’s needs became a low priority within the service milieu. It was only after she was hit by a car years later that she received some attention. However, the support given was mainly in the form of physiotherapy rather than a holistic approach that addressed her overall needs. When Wanda stopped going to her physiotherapy, she lost all contact with the health care system and the only support she has in her life is an under-resourced outreach programme with limited hours of operation and no wheelchair accessibility. The only real happiness that Wanda can recall is when she was with her children. However, her narrative of being a mother is marked by guilt, shame and regret. Over the years, Wanda attended multiple addiction treatment programmes, all in the hope of either keeping or regaining custody of her children. Once the children were permanently removed from her care and she was no longer able to get pregnant, Wanda stopped trying to overcome her addiction. No longer at risk of giving birth, the system lost interest in Wanda’s recovery and



strategies to motivate her to address her addiction all but disappeared.

Invisibility Wanda is one of a number of ‘‘invisible’’ Indigenous women who live in Canada’s most impoverished and violent neighbourhoods. Despite battling with addictions and mental illness, they face multiple barriers and service gaps when seeking supports (10,16,17). Post-treatment care is also limited and commonly the resources available are under-funded and lack women-specific programming (1719). Women like Wanda almost never meet the policy criteria for other supportive services simply because they are neither pregnant (and cannot become pregnant) and do not have children in their care: 2 criteria which are required for entrance into almost all government-funded outreach programming for women (2022). Despite their invisibility this is a vulnerable and highservice need population, who without supportive interventions, inevitably experience declining health and risk of premature death (10,15,2325). Co-occurring health problems noted in addicted women include, cirrhosis, psychiatric hospitalizations, anaemia and poor nutrition, tremors, gastrointestinal bleeding, alcohol-related cancer, hypertension, obstructive pulmonary disease, alcohol/ drug-related cognitive deficits and HIV (2,26). Lifetime co-occurrence of mental illness is high and often occurs prior to the onset of substance abuse with childhood abuse being a primary precipitating factor (5,2729). Despite the high needs of this population, in many settings Indigenous women who abuse substances are considered social ‘‘throw aways.’’ As they move through life, they are increasingly stigmatized and marginalized, making it difficult for them to seek out and sustain treatment regimes (1,5,30). Their diminished social position further places them at elevated risk for violence and exploitation (2,3). For women living in northern and remote communities, they live in a service environment that is most often lacking in the range of supports available in the south (e.g. residential addiction treatment, detox, mental health outreach, transitional housing and shelters). If Wanda wants to return to her northern reserve, it is likely there would be limited support for her mental illness, addiction or the injuries from the car accident. The ties with her community have also been severed years ago, requiring Wanda to prove her citizenship and negotiate re-entry. At this point in her life, it is unlikely that Wanada will try to move ‘‘home’’ and more likely she will remain socially isolated, without family or community.

Living policy In discussing the links between past government policies and the current state of mental health among Canadian Indigenous peoples, colleagues and I wrote in 2000:

‘‘Some of these policies were well intentioned, but most were motivated by a condescending, paternalistic attitude that failed to recognize either the autonomy of Aboriginal peoples or the richness and resources of their cultures. The cumulative effect of these policies has, in many cases, amounted to near cultural genocide. The collective trauma, loss, and grief caused by these short-sighted policies are reflected in the endemic mental health problems of many Aboriginal communities and populations across Canada’’ (31, p. 609). Despite national consensus that government policies have had devastating effects on Indigenous peoples (5, p. xv), our country struggles with sincere acknowledgement and reconciliation. For example, more Indigenous children are wards of the state today than was the case at the height of the residential school era (32,33). This is occurring despite damning research evidence that directly correlates foster placement with elevated risk of behavioral and social problems in adulthood (3436). While it is well acknowledged that CFS systems perpetuate their own brand of harm upon Indigenous children (33,37,38), there is an absence of societal moral outcry despite frequent media reporting on the problems with CFS. As a result, governments lack motivation to undertake meaningful change, including implementing ethical policies in CFS to bolster prevention and reduce childhood trauma brought on by apprehension procedures, multiple foster placements and foster home overcrowding. In areas of mental health and addictions, ethical policies could include reducing barriers to therapeutic care for all individuals, increasing the abilities of outreach programmes to support high-risk clients in treatment, the provision of intensive long-term aftercare that includes safe housing; and, reunification of children with their parents even when a parent is not in a position to be the primary guardian of that child. Attempts by Indigenous leaders and advocates to make governments more accountable and ethical in areas of health and CFS have been met by government stonewalling, and in some instances lengthy legal battles (38). It is easy to look at the lives of women like Wanda and see the myriad of government policies across generations that directly and indirectly contribute to ill health, social despair and life-long inequities. If this is the case, then how can we be assured that present-day policies are not equally as damaging? For example, it is not uncommon for children who linger in foster care to experience multiple foster placements or moves between their biological home and foster care (33,34). In some cases, young adults estimate that they were moved upwards of 2030 different times as children in care, begging the question as to who is really looking out for the best interest of these children both now, and when they reach adolescence and adulthood (39)? Policies that allow multiple foster placements to go unmonitored ignore


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compelling medical evidence documenting the elevated health and social risks caused to the child by this practice (3234). The policy and the resulting practice support the needs of the bureaucracy far more than it supports the needs of the child, and when used in the extreme, can result in life-long negative consequences. In a country as historically wealthy and prosperous as Canada, how is it that certain families are condemned at the hands of their own governments’ policies, to live the life that Wanda and her family have endured? Over 4 generations, Wanda’s family’s destiny has largely been determined by government policies and interventions despite their resilience and attempts to resist the assaults. From an ethical policy perspective, the focus of policy and the practices they generate must first and foremost ensure that individuals, families and groups are not left worse off than before government policies impact upon their lives. Furthermore, the impact of living a life determined by multiple government policies should not be a story of individual and family devastation, specifically when presumably the state is acting in the ‘‘best interest of the child’’ in cases of CFS protection, or providing ‘‘best practice’’ care to help individuals recover from mental illness and addictions. As a basis for understanding Wanda’s life, this article asks, ‘‘Have any of the lessons from the failure of past government policies yielded more humane and ethical government policies and interventions when engaging vulnerable Indigenous peoples?’’. Wanda’s story unfortunately suggests not; at least not in ways that are meaningful and sustainable to her and her family, or in ways that respect the abilities of Indigenous leaders and frontline workers to know best how to improve the lives of their people.

Conclusion The circumstances of impoverished Indigenous peoples are intimately interwoven from birth with historical and contemporary government policies and the resulting consequences of poverty, addiction, trauma, mental illness and entrenched structural violence. In today’s political climate, positive reforms to government policies and programming are limited and social welfare benefits have not kept up with inflation, forcing more people into highrisk lifestyles with no meaningful way out of poverty. In remote and northern communities, the lack of voluntary sector supports such as food banks, shelters and transitional housing adds to the vulnerability of the poor and marginalized. Women with chronic substance abuse and mental illness are at high risk of dying prematurely (10,40,41). Their health and social needs reach far beyond basic outreach services and unless forms of intensive, culturally safe therapy is offered in a place where they feel safe to begin to rebuild (or build for the first time) their lives,

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and unless this support is provided for extended periods of time (possibly the rest of their life), it is unlikely that their lives will improve. The question for Canadian society is therefore, not one of ‘‘efficiencies,’’ ‘‘quality improvement’’ and ‘‘accountability,’’ rather, when we consider the lives of vulnerable peoples in our society we must ask, ‘‘What are our moral values as Canadians?’’, ‘‘Are we as a society, morally driven to prioritize our most vulnerable citizens; those most difficult to help, and who require our commitment of both time and resources?’’, ‘‘Do we expect our governments to work towards beneficence and away from maleficence in each and every policy that targets our most vulnerable?’’. Unfortunately, even with a commitment to ethically driven policies and services there are no guarantees that individuals will fare better if they remain in neighbourhoods and communities where poverty is endemic and only limited options exist for them to transform their lives. The following words of Nelson Mandela pushes us one step further, ‘‘Like slavery and apartheid, poverty is not natural. It is man-made and it can be overcome and eradicated by the actions of human beings. And overcoming poverty is not a gesture of charity. It is an act of justice. It is the protection of a fundamental human right, the right to dignity and a decent life. While poverty persists, there is no true freedom’’ (42).

Conflict of interest and funding Funding for segments of this research and preparation of the manuscript was provided by Canadian Institutes of Health Research (Grant no. 115690).

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27. Dube SR, Anda RF, Whitfield CL, Brown DW, Felitti VJ, Dong M, et al. Long-term consequences of childhood sexual abuse by gender of victim. Am J Prev Med. 2005;28:4308. 28. Brems C, Johnson ME, Freemon M. Childhood abuse history and substance use among men and women receiving detoxification services. Am J Drug Alcohol Abuse. 2004;30:799821. 29. Lo CC, Cheng TC. The impact of childhood maltreatment on young adults’ substance abuse. Am J Drug Alcohol Abuse. 2007;33:13946. 30. Roberts G, Ogborne A. Profile: substance abuse treatment and rehabilitation in Canada. Ottawa: Ministry of Public Works and Government Services Canada; 1999. 31. Kirmayer L, Brass GM, Tait CL. The mental health of aboriginal peoples: transformations of identity and community. Can J Psychiatry. 2000;45:60716. 32. Blackstock C. Residential schools: did they really close or just morph into child welfare? Indigenous Law J. 2007;6:718. 33. Saskatchewan Child Welfare Review Panel. For the good of our children and youth: a new vision, a new direction. 2010. Available from: http://saskchildwelfarereview.ca/CWR-panelreport.pdf. 34. Coy M. ‘‘Moved around like bags of rubbish nobody wants’’: how multiple placement moves can make young women vulnerable to sexual exploitation. Child Abuse Rev. 2009;18: 25466. 35. Reilly T. Transition from care: status and outcomes of youth who age out of foster care. Child Welfare. 2003;82:72746. 36. Leslie LK, James S, Monn A, Kauten MC, Zhang J, Aarons G. Health-risk behaviors in young adolescents in the child welfare system. J Adolescent Health. 2010;47:2634. 37. Blackstock C, Brown I, Bennet M. Reconciliation: rebuilding the Canadian child welfare system to better serve Aboriginal children and youth. In: Brown I, Chaze F, Fuchs D, Lawrence J, McKay S, Thomas SP, editors. Putting a human face on child welfare: voices from the prairies. Regina: Prairies Child Welfare Consortium; 2010. p. 5997. 38. Fournier S, Crey E. Stolen from our embrace: the abduction of First Nations children and the restoration of Aboriginal communities. Vancouver and Toronto: Douglas & McIntyre; 1997. 39. Tait CL, Cuthand D. Child welfare: the state as parent. [documentary]. Saskatoon: Bluehill Productions; 2011. 40. Abel EL. Fetal alcohol abuse syndrome. New York: Plenum Press; 1998. 41. Abel EL, Hannigan JH. Maternal risk factors in fetal alcohol syndrome: provocative and permissive influences. Neurotoxicol Teratol. 1995;17:44562. 42. Mandella N. In full: Mandela’s poverty speech. BBC News; 2005 Feb 3 [cited 2012 Nov 29]. Available from: http://news. bbc.co.uk/2/hi/uk_news/politics/4232603.stm. *Caroline L. Tait Department of Psychiatry Applied Research Unit Box 55, Royal University Hospital Saskatoon, SK S7N 0W8 Canada Email: [email protected]


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BEHAVIORAL HEALTH

Discovering unique tobacco use patterns among Alaska Native people Julia A. Dilley1*, Erin Peterson2, Vanessa Y. Hiratsuka3 and Kristen Rohde1 1

Program Design and Evaluation Services, Multnomah County Health Department and Oregon Health Authority, Portland, OR, USA; 2Alaska Department of Health and Social Services, Anchorage, AK, USA; 3 Southcentral Foundation, Anchorage, AK, USA

Background. Alaska Native people are disproportionately impacted by tobacco-related diseases in comparison to non-Native Alaskans. Design. We used Alaska’s Behavioral Risk Factor Surveillance System (BRFSS) to describe tobacco use among more than 4,100 Alaska Native adults, stratified by geographic region and demographic groups. Results. Overall tobacco use was high: approximately 2 out of every 5 Alaska Native adults reported smoking cigarettes (41.2%) and 1 in 10 reported using smokeless tobacco (SLT, 12.3%). A small percentage overall (4.8%) reported using iq’mik, an SLT variant unique to Alaska Native people. When examined by geographic region, cigarette smoking was highest in remote geographic regions; SLT use was highest in the southwest region of the state. Use of iq’mik was primarily confined to a specific area of the state; further analysis showed that 1 in 3 women currently used iq’mik in this region. Conclusion. Our results suggest that different types of tobacco use are epidemic among diverse Alaska Native communities. Our results also illustrate that detailed analysis within racial/ethnic groups can be useful for public health programme planning to reduce health disparities. Keywords: Alaska/epidemiology; Smoking/epidemiology; Prevalence; Smoking/ethnology; Indians; North American; Tobacco; smokeless

he term Alaska Native is used to refer to the Indigenous inhabitants of the land that is now the state of Alaska. The more than 138,000 Alaska Native people (single or multi-race) now living in Alaska make up about 24% of its residents (1). The state of Alaska is one-fifth the size of the continental United States, and many areas of the state can only be reached by boat or plane (2). Alaska’s Native people have historically been geographically distant from one another and thus have grown culturally diverse. The more than 200 tribes fall into 5 distinct Alaska Native cultural subgroups: Inupiaq; Athabascan; Yup’ik and Cup’ik; Aleut and Alutiiq; and the Eyak, Tlingit, Haida and Tsimshian (3). However, despite this diversity, most reports published in the US provide health behavior estimates only for ‘‘American Indian/Alaska Native’’ people combined across the nation (4). In a Surgeon General’s report (5) that presented smoking prevalence among different American Indian/Alaska Native (AIAN) subgroups, Alaska Native people had the highest reported smoking prevalence among all AIAN or Native American cultural groups.

T

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The Nicotiana tobacco plant is not a naturally occurring plant to Alaska, and therefore did not historically have traditional significance for Alaska Native people, as it does for some other Native American groups (6); however, commercial tobacco use is now common among Alaska Native people. In a recent report by Alaska’s Department of Health to describe tobacco use specifically among Alaska Native people, prevalence among Native peoples was significantly greater than, and approximately twice the prevalence among nonNative Alaskans (7). For example, in 2005, 40.6% of Native versus 22.0% of non-Native Alaskan adults smoked cigarettes, and 10.8% of Native versus 2.0% of non-Native Alaskan adults used smokeless tobacco (SLT). Kim et al. used a statewide survey of women who had recently delivered a child and reported that more than 40% of Alaska Native women used some form of tobacco during pregnancy (8). Angstman et al. found 12% current SLT use among adolescents aged 610 and 44% among aged 1518 using medical records from the YukonKuskokwim Native Health Corporation (9). These findings provide ample evidence that Alaska


Tobacco use among Alaska Native people

Native people deserve intensive support for tobacco control, and further analysis is needed to understand patterns of tobacco use within the population. In addition to commercial tobacco products, a number of reports, beginning in the 19th century, have described the use of an SLT variant called ‘‘iq’mik’’ (pronounced ‘‘ick-mick’’) or ‘‘Blackbull’’ that is unique to Alaska Native communities in the southwest region of the state (6,1013). Iq’mik is prepared by burning a woody fungus (Phellinus igniarius) from birch trees, and mixing the ash with leaf tobacco. The ash is mixed with tobacco leaves, pre-chewed in the mouth or mixed with water, and stored in containers to use later. Iq’mik is frequently shared among families; parents in some regions reportedly introduce children to use early, including as a teething remedy for infants (6,11). This early introduction of iq’mik to young children may explain results from a study of 36-year-old preschoolers, where 3.5% were found to have saliva cotinine levels far exceeding levels consistent with secondary exposure, and suggestive of primary tobacco use by the children (14). Perham-Hester used a statewide survey of women who had recently delivered a child and reported that 4.1% of Alaska Native women statewide had used iq’mik during pregnancy (15). Not surprisingly, rates of tobacco-related diseases such as lung and mouth cancers (1618), heart disease and stroke (19), and chronic obstructive pulmonary disease (COPD) (20) are also greater among Alaska Native people than among non-Natives in Alaska or US Whites. Additionally, excess rates of infant death and illness among Alaska Native people can be partially attributed to prenatal smoking and second-hand smoke exposure (21). Some of these studies have called for more detailed descriptive studies of Alaska Native health risk behaviors by geographic area and ethnicity to aid in planning interventions (19). The purpose of our study is to describe tobacco use rates for different types of tobacco among Alaska Native people, including in specific sub-regions of the state. Our study is the first to provide population-based statewide and regional estimates for tobacco use, including iq’mik, among the general population of Alaska Native adults.

Methods We used data from Alaska Native people included in the Alaska Behavioral Risk Factor Surveillance System (BRFSS) for 20062010 combined. BRFSS is an anonymous telephone survey of adults conducted by the Alaska Division of Public Health since 1991 in cooperation with the Centers for Disease Control and Prevention (CDC). The survey includes questions about healthrelated behaviors and health status. Interviews are conducted throughout the year. The BRFSS uses a random digit dial method to select a representative sample of Alaska adults (aged 18

and older). The state sample is stratified into 5 regions, with roughly equal numbers of interviews conducted in each region. One survey respondent from each selected household is randomly chosen from among the adults living in the household. People without home-based telephones are not eligible for sampling (that is, persons living in dormitories, military housing, prisons, nursing homes and other institutional settings). Cell phones are not available for sampling, so individuals who use only cell phones as their home telephone are ineligible. Alaska’s BRFSS is administered only in English.

Measures Alaska Native race We identified Alaska Native respondents as people who reported their race as ‘‘American Indian or Alaska Native’’ alone, or as their preferred race. Although the survey response option is phrased as ‘‘American Indian or Alaska Native’’ (AIAN), we use the term ‘‘Alaska Native’’ in this paper because most AIAN people living in Alaska more specifically identify as Alaska Native, and this is the language commonly used in Alaska, and by Native organizations, to refer to the Indigenous people living in the state (22). Demographic characteristics Respondents provided their exact age and highest level of formal education completed. They also provided information about total household income (estimated), and whether there were children in the home. Geographic region We created geographic regions based on service areas for the state’s Native Health Corporations (tribal and Native health organizations that provide health services and related programmes). Individuals were assigned to a region based on telephone prefix, which is linked to specific geographic areas in Alaska. Cigarette smoking Respondents who had smoked at least 100 cigarettes in their lifetime and currently smoke ‘‘every day’’ or ‘‘some days’’ were coded as current smokers. Smokeless tobacco Respondents who said that they currently used any SLT products such as chewing tobacco or snuff, iq’mik or Blackbull were classified as current users. Iq’mik We classified respondents as iq’mik users if they responded ‘‘yes, iq’mik or Blackbull’’ to the BRFSS question ‘‘Do you currently use any smokeless tobacco products such as chewing tobacco or snuff, iq’mik, or Blackbull?’’ Unfortunately, one of the response options to the question about SLT was ‘‘more than one’’ and since it would be possible to give this answer and not use


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iq’mik, we did not classify people who gave this response as users and thus the true prevalence of iq’mik use may be higher than we are reporting here.

Analysis We used unweighted data to describe the sample population, and weighted the data for tobacco use prevalence estimates to adjust for sampling design (based on region and telephone listing), and for the number of telephones and adults in each household. Weighted data were also post-stratified to the age and sex distribution of the Alaska population. We used the Pearson Chi-square test of independence to determine whether different types of tobacco use were associated with distributions of age, gender, education, income and having children in the home. We stratified by Alaska Native Health Corporation regions, combining smaller regions so that there were at least 50 respondents in any group, to describe geographic patterns of tobacco use among Alaska Native people. Analyses were completed using Stata/IC 10.1† , and using a significance level of 0.05.

Results Table I describes the unweighted characteristics of the 4,143 Alaska Native adults included in Alaska’s BRFSS in the years 20062010. About half of the respondents were under age 45, and more than half had children living in the home. Approximately one-third had any college education and about 3 out of 4 reported a household income of less than $50,000 per year. Respondents were spread throughout 12 regions of Alaska. Table II shows tobacco use prevalence among different subgroups. Approximately 2 out of every 5 Alaska Native adults reported smoking cigarettes (41.2%). About 1 in 10 reported using some type of SLT (12.3%), and a relatively small percentage statewide (4.8%) reported using iq’mik alone. When cigarettes and SLT were combined, about half of Alaska Native adults were currently using some type of tobacco product. Both cigarette smoking and SLT use were significantly associated with age, gender, education, income and having children in the home. Highest smoking prevalence was measured among younger adults (51.8% among people aged 2534), men (44.7%), people with the least years of formal education (48.7% among those with less than high-school education), lowest household income (48.5% among people in households with less than $15,000 per year), and people with children in the home (45.2%). SLT use prevalence was highest among middle-aged people (15.7% among 3544), men (15.7%), people with less formal education (15.3% among people with less than high-school education), lowest income (17.2% among

208

people in households with less than $15,000 per year) and people with children in the home (15.4%). Iq’mik use was not significantly associated with age or gender, but was significantly associated with education, income and having children in the home. Iq’mik use prevalence was highest among people with less formal education (6.7% among people with less than high-school education), lowest income (8.4% among people with household income less than $15,000) and people with children living in the home (6.8%). Use of either cigarettes or SLT was significantly associated with all demographic characteristics, with more than half of Alaska Native adults using some form of tobacco in several subgroups: adults younger than 55 years, males, people with a high-school education or less, people with household income less than $50,000 per year and people who had children in the home. Table III shows the prevalence of cigarettes, any SLT, iq’mik alone, and all tobacco combined, stratified by geographic region. Figure 1 shows maps for ranges of cigarette and SLT use across Alaska’s regions. More than half of Alaska Native adults in the Aleutians/Pribilofs (53.6%), Arctic Slope (54.6%), Bristol Bay (50.3%), Northwest Arctic (52.5%) and Norton Sound (52.3%) health corporation regions reported current smoking. The lowest smoking prevalence, 32.8%, was reported in the Copper River/Prince William Sound region. More than one-third of Alaska Native adults in the YukonKuskokwim (YK) region reported current use of SLT (37.5%), which was significantly higher than for any other region of the state; Anchorage/Mat-Su (2.7%) and Southeast (2.7%) had lower SLT use prevalence than many other regions of the state. SLT use prevalence ranged from 4.5 to 13% in other regions of the state. Use of iq’mik was almost entirely confined to the YK region (23.3%). When combining cigarette and SLT use, only 5 of the 12 regions had less than half of the adults reporting current use of tobacco. The highest prevalence was measured in the YK region, where about two-thirds (66.4%) of adults reported using some type of tobacco. Finally, we explored data from the YK region alone to examine factors associated with iq’mik use, since iq’mik use was primarily confined to that region. Women in the YK region were significantly more likely than men to use iq’mik (30.1% vs. 17.8%; data not shown). Higher income was associated with decreased prevalence of iq’mik use (23.427.1% among people with less than $50,000 household income per year vs. 1.616.8% among people with more than $50,000 per year). Iq’mik use in the YK region was not significantly associated with age, having children in the home, or highest level of formal education, although small numbers may have prevented us from detecting associations.



Table I. Characteristics of Alaska Native adults, Alaska BRFSS 20062010 (N4,143) Characteristics

N

Percent

Age 1824

409

10.1

2534

784

19.4

3544

816

20.1

4554

938

23.2

5564

682

16.8

423

10.4

Male

1,842

44.5

Female

2,301

55.5

815

19.8

65 and above Gender

Highest education Less than high-school graduate High-school graduate or

1,940

47.1

GED College 13 years

977

23.7

College graduate

390

9.5

Less than $15,000

741

22.1

$15,00024,999

762

22.8

$25,00049,999

909

27.2

$50,00074,999

428

12.8

$75,000 or more Children in the home

508

15.2

No children in home

1,307

41.0

Children living in the

1,883

59.0

Alaska Native Health Corporation% Aleutians and Pribilofs 104

2.5

Household income

home

Anchorage/Mat-Su

307

7.4

Arctic Slope Bristol Bay

176 302

4.3 7.3

70

1.7

Interior

553

13.4

Kenai Peninsula

213

5.1

Kodiak

121

2.9

Northwest Arctic

315

7.6

Norton Sound Southeast

373 635

9.0 15.3

YukonKuskokwim

973

23.5

Copper River/Prince William Sound

%

Assigned by telephone prefix.

Discussion In this study, we were able to identify different patterns of tobacco use by Alaska Native adults in different regions of the state, and among different demographic subgroups. We organized the information in this study according to geographic regions served by Alaska Native Health Corporations, so that the results would be as relevant

and portable as possible for use by stakeholders prioritizing and planning effective programmes to support Alaska Native people. Having detailed information to describe patterns of tobacco use is an important component of working to decrease use and disparities. For example, health goals were established specifically for Alaska Native people as part of the state’s ‘‘Healthy Alaskans 2010’’ initiative. These goals included reducing smoking to 14% or less, and reducing the use of SLT to 3% or less (from respective baselines of 42 and 12% among Alaska Native adults statewide in 1999) (23). It seems unlikely that these goals have been met. Understanding what segments of the Alaska Native population are at greatest risk will help to achieve these ambitious and important goals. The prevalence of cigarette smoking among Alaska Native people was high in all regions, but prevalence was highest in some of the most remote areas of Alaska. Smoking prevalence was lower in the relatively more urban Anchorage/Mat-Su and Southeast (Juneau) areas. These areas are also where proven tobacco control interventions such as tax increases and smoke-free workplaces have been most aggressively applied: although not designed to reach Alaska Native people specifically, such interventions may influence all people who live there. This difference in regional prevalence may be related both to the difficulty in sufficiently funding and supporting programmes across the vast state, and to translating ‘‘best practice’’ tobacco control interventions (such as policies and healthcare interventions) to frontier village environments. However, because so many Alaska Native people live in such environments, it is highly unlikely that overall goals for reducing tobacco use and improving population health can be met unless these programmes are adapted or re-conceptualized to be effective in very rural settings. The YK region shows a particularly unique pattern of tobacco use: although among the lower prevalence regions for cigarette smoking, it was among the highest region for SLT use. Furthermore, as had been reported in a small number of isolated studies, we confirmed empirically that the use of iq’mik was primarily concentrated in the YK region. Upon further stratification, we found that approximately 1 in 3 Alaska Native women in the YK region reported using iq’mik, significantly more than men. This is consistent with other reports of high prevalence of iq’mik use among women of childbearing age in Southwest Alaska (12,13,24). Our findings provide additional evidence from a population-based public health surveillance system of the need for support to reduce tobacco use, especially SLT use, among Alaska Native women in this area of the state. Wolsko et al. (25) found that the use of iq’mik was more highly prevalent among Yup’ik adults practicing traditional lifestyles, while cigarette smoking was more highly prevalent among Yup’ik adults practicing Western


209


210 Table II. Tobacco use among Alaska Native adults by demographic group, Alaska BRFSS 20062010 Cigarettes %

(95% CI)

41.2

1824 2534

Any smokeless %

(95% CI)

(38.743.7)

12.3

47.4

(40.055.0)

51.8

(45.757.8)

3544 4554

40.2 38.8

(35.645.0) (34.543.2)

5564

34.0

(29.239.2)

65 and older

21.1

(15.927.5)

44.7

(40.948.5)

37.6

(34.640.6)

48.7 45.4

(43.154.3) (41.749.2)

All Alaska Native adults

p

Iqmik alone p

%

(95% CI)

(11.013.7)

4.8

12.0

(8.716.2)

14.4

(11.118.3)

15.7 12.2

(12.918.9) (9.715.1)

Any tobacco p

%

(95% CI)

(4.15.6)

51.3

(48.853.8)

4.8

(2.97.7)

55.9

(48.163.4)

4.3

(3.06.2)

61.7

(55.867.3)

6.2 5.2

(4.68.3) (3.77.2)

52.9 50.5

(47.857.9) (45.855.2)

5.0

(3.27.6)

43.0

(37.948.3)

1.8

(0.83.8)

27.1

(21.233.8)

4.1

(3.25.3)

56.0

(52.259.8)

5.5

(4.46.8)

46.4

(43.249.6)

6.7 6.0

(4.99.2) (4.87.4)

59.7 57.3

(54.065.2) (53.660.9)

2.4

(1.63.8)

43.7

(39.048.6)

1.3

(0.43.8)

26.2

(20.033.5)

p

Age


B0.001

10.2

(7.314.1)

4.3

(2.67.1)

15.7

(13.618.2)

8.7

(7.410.3)

15.3 14.7

(12.119.1) (12.717.0)

0.002

0.17

B0.001

Gender Male Female Highest formal education Less than high-school graduate High-school graduate or GED College 13 years

35.4

(31.040.1)

College graduate

20.8

(15.227.8)

Less than $15,000

48.5

$15,00024,999

49.3

$25,00049,999 $50,00074,999 $75,000 or more Children in the home

0.004

B0.001

0.08

8.3

(6.211.2)

5.3

(3.19.0)

(42.554.7)

17.2

(13.721.3)

8.4

(6.211.2)

60.8

(54.566.7)

(43.854.9)

12.6

(9.716.1)

5.0

(3.67.1)

57.8

(52.263.2)

40.9

(35.546.5)

11.9

(9.215.2)

5.1

(3.57.3)

51.1

(45.556.6)

36.9 27.4

(29.245.3) (20.435.7)

B0.001

8.2 4.0

(5.611.9) (2.66.1)

1.4 0.1

(.53.7) (0.7)

45.3 31.3

(37.353.6) (24.039.6)

No children in home

36.1

(32.240.1)

7.7

(6.09.8)

2.3

(1.53.7)

43.4

(39.247.7)

Children living in the home

45.2

(41.349.1)

0.001

15.4

(13.317.8)

6.8

(4.36.1)

57.3

(53.561.1)

B0.001

B0.001

B0.001

B0.001

B0.001

Household income

B0.001

B0.001

Estimates weighted to adjust for sampling design, and post-stratified to state population for age and gender.

B0.001

B0.001

B0.001

B0.001


Table III. Tobacco use among Alaska Native adults by Alaska Native Health Corporation Region, Alaska BRFSS 20062010 Cigarettes

Any smokeless

Percent*

(95% CI)

Percent*

Aleutians and Pribilofs

53.6

(42.764.2)

13.0

Anchorage/Mat-Su Arctic Slope

37.3 54.6

(30.145.0) (45.463.4)

2.7 4.5

Bristol Bay

50.3

(42.757.9)

Copper River/Prince William Sound

32.8

(21.146.9)

Interior

42.7

Kenai Peninsula

(95% CI)

Iqmik alone

All tobacco combined

Percent*

(95% CI)

Percent*

(95% CI)

(6.823.3)

1.7

(0.47.6)

61.3

(50.171.4)

(1.35.6) (1.910.4)

0.1 0

(00.4)

39.5 60.7

(32.347.2) (51.369.4)

13.0

(8.719.0)

1.6

(0.64.1)

57.1

(49.064.7)

9.1

(3.322.6)

1.9

(0.312.5)

42.3

(28.757.1)

(37.648.0)

9.5

(6.813.0)

0.1

(00.4)

51.0

(45.856.2)

38.4

(30.646.7)

9.7

(5.516.3)

2.5

(0.69.5)

47.2

(38.955.7)

Kodiak

38.1

(27.849.6)

5.3

(2.312.2)

0.6

(0.14.3)

44.8

(33.956.3)

Northwest Arctic

52.5

(45.759.2)

12.1

(7.718.4)

0.5

(0.13.4)

62.0

(55.268.3)

Norton Sound Southeast

52.3 36.6

(46.258.4) (32.241.3)

10.4 2.7

(6.416.4) (1.45.3)

0.8 0

(0.23.1)

YukonKuskokwim

36.4

(32.540.5)

37.5

(33.641.6)

23.3

(20.026.9)

63.5 39.9 66.4

(57.269.3) (35.344.7) (62.769.9)

Alaska Native Health Corporation%

*Estimates weighted to adjust for sampling design, gender and age. Assigned by phone prefix.

%

lifestyles. We did not have measures of cultural lifestyle in our study, but we noted that the use of iq’mik was not significantly associated with age, in contrast to smoking (which showed a more typical pattern of higher use among young adults). This pattern could be explained by differences in lifestyle practices, if younger adults are less likely to practice traditional lifestyles than older adults. Future development of some measures of traditional versus Western lifestyle practice may be useful for better understanding the association between health-related practices and diverse cultures. Although we described tobacco use separately for cigarettes and SLT, it is also important to understand individual practices for blending or switching behaviors. Focus group participants in other studies have reported that men often switch from iq’mik to cigarettes as adults, while women continue using iq’mik, and yet others may switch to iq’mik when quitting cigarettes or if cigarettes are not available (11). Patten (26) recently documented a surprising increase in the prevalence of (any) SLT use from 14% pre-pregnancy to 60% during pregnancy in the YK health corporation population. We found that the use of multiple tobacco products was frequent among Alaska Native adults in some areas of the state. Also, we noted that SLT use was higher among people with children in the home. Interventions may benefit from anticipating tobacco type-switching behaviors, and exploring the reasons behind them, in Alaska Native communities. We found different patterns of tobacco use among Alaska Native adults in different regions of the state, but we did not find any areas of the state where tobacco interventions were not needed. Huge gaps exist in the

identification of culturally appropriate and effective health promotion programmes, and ways to disseminate those programmes (27). Past efforts to reduce tobacco use specifically among Alaska Native people have included the integration of tobacco cessation clinical best practices into Alaska Native health corporation systems that provide health services to Alaska Native people (28), targeted culturally appropriate education programmes such as the Traditions of the Heart cardiovascular disease screening and education programme for under-insured Alaska Native women (29) and funding communitybased programmes in rural areas largely populated by Alaska Native people. To address the problem of tobacco, some communities have implemented highly successful campaigns to implement local tobacco taxes, which are effective for preventing youth from starting to use tobacco and for helping adults to quit (30). Notably, the largely Alaska Native community of Bethel implemented a $2.21 per-pack tobacco tax in February 2013, placing Bethel among the top 10 in the nation for the application of price interventions; other Alaska communities including Anchorage, Barrow, Matanuska-Susitna Borough, Sitka, Juneau, and Fairbanks also rank among the leading communities in the nation (31). Future data collection and analyses may reveal the anticipated benefits of these recent interventions.

Limitations Data from the Alaska BRFSS used in this report may not accurately represent the whole Alaska Native population. For example, Schumacher et al. (32) reported that 8% of Alaska Native respondents in the EARTH study spoke only Alaska Native languages. These Alaska Native people would not be included in BRFSS, which is


211


Fig. 1. Prevalence of current tobacco use among Alaska Native adults, by Alaska Native Health Corporation Region.

available only in English, and their tobacco use patterns may be different than those of people who speak English (alone or in combination with other languages). The survey also excludes people without a telephone landline, who may have different patterns of tobacco use.

212

Tobacco use may be underestimated in our study because people might be reluctant to report behaviors/ attitudes that others might not find acceptable (particularly over the phone to a stranger). Information from community stakeholders suggests that Alaska Native



people may in particular be uncomfortable participating in telephone surveys and revealing personal information over the telephone. Our measure of iq’mik use was problematic because one response option to the question ‘‘what type of smokeless tobacco do you use?’’ was ‘‘more than one product.’’ It is very likely that some people use iq’mik in combination with commercial SLT or snuff, and these people would not have been classified as iq’mik users in our analysis because we could not confirm their use. If all of the ‘‘multiple product’’ users were also using iq’mik, the real prevalence of iq’mik use may be higher than reported here.

6. 7.

8.

9.

Conclusions Tobacco use is highly prevalent among Alaska Native people, throughout Alaska, but patterns of product use are different in different regions. These unique patterns of tobacco use may be considered when deploying interventions to reduce tobacco use regionally or statewide, and suggest that more culturally appropriate interventions are needed to address specific products, and for rural communities. Continued monitoring of trends in tobacco use for different regions of the state may help to identify areas of the state that are successful in reducing tobacco use and inform the evolution of ‘‘best practices’’ for Alaska Native communities. Our findings also illustrate the importance and utility of conducting descriptive investigations within subpopulations of a racial/ethnic minority subgroup.

10.

11.

12.

13.

14.

15.


16.

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Native women: the traditions of the heart project. Int J Circumpolar Health. 2007;66(Supp1):3944. 30. Campaign for Tobacco Free Kids. Top combined state-local cigarette tax rates. Washington, DC. 2012 [cited 2013 Mar 31]. Available from: http://www.tobaccofreekids.org/research/ factsheets/pdf/0267.pdf 31. Community Preventive Services Task Force. Guide to community preventive services. Reducing tobacco use initiation: increasing unit price of tobacco products. 1999 [cited 2013 Mar 31]. Available from: www.thecommunityguide.org/tobac co/initiation/increasingprice.html 32. Schumacher MC, Slattery ML, Lanier AP, Ma KN, Edwards S, Ferucci ED, et al. Prevalence and predictors of cancer screening among American Indian and Alaska Native people: the EARTH study. Canc Causes Contr. 2008;19:72537. *Julia A. Dilley 827 NE Oregon Street Suite 250, Portland, OR 97232 USA Tel: 1-360-402-7877 Fax: 1-971-673-0590 Email: [email protected]



Intimate partner violence in the Canadian territorial north: perspectives from a literature review and a media watch Pertice Moffitt1*, Heather Fikowski2, Marshirette Mauricio2 and Anne Mackenzie2 1

Health Research Programs, Aurora Research Institute, Yellowknife, Canada; 2Aurora College, Yellowknife, Canada

Introduction. Family violence is a complex, multidimensional and pervasive presence in many Aboriginal communities. Although practitioners acknowledge that intimate partner violence (IPV) is a grave concern in the North, as in other jurisdictions in Canada, there is a paucity of literature about IPV and the local response to that violence. Objective. The purpose of this study is to report on a synthesis of Northern Territorial literature and a 3-year media watch conducted in the Canadian territories. Design. This review is part of a multidisciplinary 5-year study occurring in the Northwest Territories (NT) and northern regions of the Prairie Provinces of Canada. The methods included a review of the literature through CINAHL, PubMed, Academic Search Complete, Social Sciences Index and JSTOR (19902012) combined with a media watch from 2009 to 2012. A thematic content analysis was completed. Results. Themes included: colonization; alcohol and substance use; effects of residential schooling; housing inadequacies; help-seeking behaviors; and gaps within the justice system. Identified themes from the media watch were: murders from IPV; reported assaults and criminal charges; emergency protection orders; and awareness campaigns and prevention measures. Conclusion. When synthesized, the results of the literature review and media surveillance depict a starting context and description of IPV in the Canadian territories. There are many questions left unanswered which build support for the necessity of the current research, outline the public outcry for action in local media and identify the current published knowledge about IPV. Keywords: intimate partner violence; domestic violence; Canadian North; media watch; literature review

iolence is intolerable and destructive to individuals, families, communities and to all societies. In the Canadian territories, as in other parts of the circumpolar world, intimate partner violence (IPV) is, unfortunately, well known to the people who live there. The effects of IPV are discussed publicly by local activists in the hope of obliterating its occurrence and yet whispered behind closed doors in some remote locations where relationships are intimately bound. The variables that increase the incidence of IPV are intermingled with the support, or lack thereof, as well as the uniqueness of Aboriginal and remote communities. Furthermore, these confounding variables as well as the micro and macro effects of IPV are traumatic and intersect private and public domains. There is a paucity of published academic

V

literature about IPV in the Canadian north, but stories of charged perpetrators, victims and fatalities appear in abundance in the local newspapers. For that reason, the methods in this study combine a focused literature review with a media watch from 2009 to 2012. Similarities do exist between circumpolar countries especially in rural and remote areas where there are rugged terrains in isolated locations, arctic temperatures, isolation, small populations and limited resources. For that reason, the experience in the northern Territories of Canada may resonate with the IPV experience in other countries. The impact of the western world colliding with traditional values and lifeways along with colonization has disenfranchised people. These experiences may be felt across the circumpolar world. Furthermore, there is a


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need to explicate rural and remote context and experiences since the more prevalent urban interventions do not fit in the northern regions, which are distinctly different. This study begins with a background to both the definition of IPV and a context to the unique northern region within which services are provided to women and their children experiencing IPV. A description of methods utilized within the review is provided. The results of the systematic literature review and media watch are identified as well as considerations for practice, policy, research and education in the Canadian North.

Background IPV is defined as coercive, harmful and abusive behavior, such as physical, sexual, emotional and/or psychological abuse, by a current or former partner within an intimate relationship (1). This includes the existence of and/or threat of future violence. Other terms commonly used include domestic violence, spousal abuse and women abuse. Understanding IPV as a health and social issue requires exploring the problem in context (2). The regions within the vast territorial Canadian North, including Yukon (YT), Northwest Territories (NT) and Nunavut (NU), have their own unique geographic, economic, political and cultural features that are important to understand when considering the lived experience of women and their families who encounter IPV (3,4). The territories have a significantly lower population in comparison to the provinces in Canada, which contradicts the incredibly vast geographic area that these 3 territories encompass. In 2011, the population of YT was 33,897, NT was 41,462, and in NU it was 31,906 (5). To further compound the low population base, the distribution of residents is scattered over a large geographical area into many small and remote communities. A number of the communities cannot be accessed by road and are solely supported by fly-in services or, where possible, seasonal ice roads. This geographical isolation with inherent limited services means that women experience IPV differently. It also poses many challenges in the service response to IPV, such as access and availability of formal resources. For example, in the NT there are 33 communities but at this time, only 5 have emergency housing shelters for women and families fleeing abusive situations. Also, these few shelters are not always able to provide services due to funding and/or staffing shortages. In addition to the paucity of shelter services, many women are required to leave their home communities to access assistance. This isolates them, not only from family support, but also from their culture. In addition to a severe lack of shelter services, 11 communities do not have Royal Canadian Mounted Police (RCMP) detachments. Subsequently, a

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violent incident in one of these communities may have women waiting hours for authorities to arrive. The low community populations within the NT, often only a few 100 people, have additional complexities to women experiencing IPV beyond a lack of formal services, or their less frequent use of them. The very short web of relationships within a community makes it difficult and uniquely complex in terms of accessing formal supports and/or services. For example, the abusive partner may be a relative of an important community leader or service provider, such as the local band council, employed at the Health Centre or local airport. These intersecting relationships can further complicate a woman’s experience, willingness or ability to access services. It asks the question if indeed it may add to her fear, silence and success in fleeing a violent relationship. Aboriginal people encompass a huge proportion of the territories, with First Nations, Me´tis or Inuit people living in 85% of NU, 51% of NT and 23% of YT. We acknowledge that IPV is a form of violence against women, Existing literature on IPV specifically denotes family violence, spousal or domestic violence or IPV as a serious issue faced by Aboriginal women and more generally, within Aboriginal communities (610). ‘‘Aboriginal people themselves say that the problem of family violence is so serious, that it has gone beyond hurting families’’ [to harming the entire community] (11). Campbell (7) suggests that the estimated high rates of violence in Aboriginal families are not reflecting an accurate depiction of violence occurring; we should assume the reality of violence to be considerably higher. This stems from acknowledging the slim chance that violent IPV incidents get reported to the authorities. One Canadian study looked at gender differences and socio-economic characteristics to IPV experiences (12). These researchers found a greater likelihood and increased severity of IPV experiences in women, and particularly those who are also Aboriginal, younger, with a lower annual household income, lower education, economically dependent and raising young children.

Methods The electronic databases used for this literature review included CINAHL with Full Text, PubMed, Academic Search Complete, Social Sciences Index and JSTOR using 2 different search engines Proquest and EBSCOhost (19902012). We also included a review of government documents, local reports and 2 dissertations relevant to the project. Keywords used included: domestic violence, family violence, IPV, spousal assault, battered women, violence against women and conjugal violence in the YT, NT, NU and Northern Canada. A secondary search through references within articles that met our selection criteria was also completed. Articles were selected if they met 2 particular criteria.


Intimate partner violence

First of all, articles were included that reported on research (both qualitative and quantitative) results about IPV. Second, articles were included that provided results that occurred in the 3 territories and Northern provinces. Since there is very little published research from the Canadian Territories, we saw merit in expanding the accumulated data to include local sources of information and a review of media from 2009 to 2012. This included news and online reports from the Canadian Broadcasting Corporation (CBC) North and the 2 territorial newspapers. Keywords were used to search on-line news as well as a real-time surveillance of news reports. Newspaper articles were printed, collated and categorized by a central topic. Although non-academic, these documents add a context to what is publicly known or perceived about incidents in the Canadian North. From these, themes were assigned based on analysis of media collected over the 3-year period.

Ethical approval and research license This project has received ethical approval from the Research Ethics Board at the University of Regina and a research license from the Aurora Research Institute.

Systematic review of literature In Canada, most IPV research has been concentrated within more southern and urban locations; little work has highlighted rural areas and/or the Canadian North. This changed in 2004 when Statistics Canada’s General Social Survey (GSS) piloted a survey on victimization and collected data from residents in the NT, NU, and YT (13). Though somewhat under-studied, several themes emerged within this literature review including colonization, alcohol and substance use, effects of residential schooling, housing inadequacies, help-seeking behaviors and gaps within the justice system.

Colonization Among Aboriginal people in Canada, family violence is a social issue that evolved as a consequence of social injustices and cultural oppression experienced with colonization (14). The high incidence rates of IPV with Aboriginal women (15,16) and in Aboriginal communities have been closely linked to historical and prevailing colonization (17). The 1999 GSS reported 21% of Aboriginal people in Canada, as compared to 6% of non-Aboriginal people, experiencing some form of physical or sexual violence by an intimate partner within the last 5 years (18). Furthermore, the 2009 GSS reported IPV experiences were more common among Aboriginal people in Canadian territories; 1 in 10 residents reporting spousal assault had contact with that former or current partner. Colonization not only transformed the geographical location of Aboriginal people but also shifted gender regime away from males, most obviously in the mid-1970s

(19). For example, IPV rates among the Inuit in NU were the highest in Canada and the rate seemed higher after they were resettled from the land into hamlets (15). Disproportionate rates across the 3 Canadian territories were also reported in the 2009 GSS. The NT and NU reported 12 and 14%, respectively as compared to a lower proportion found in YT of 6%. The patriarchal nature of North American society was introduced with colonization. There was a shift from an egalitarian Aboriginal society, where men and women shared equal power in the subsistence economy, to the post-colonial society. Aboriginal men struggled to impose patriarchy amidst a socio-economic downturn as women became the main wage earners. Post-resettlement, Inuit women were more likely to embrace schooling and became employed outside the home. Among the Dene people, women were more likely to attain higher education, training and become the wage earners as compared to their male counterparts. Additionally, men’s more traditional wage-earning roles, trapping and hunting, were experiencing a decline. This led to a situation wherein men were threatening violence to women who were expressing an interest in advanced education. Within Aboriginal families, post-colonial changes led to a power shift between genders as well as within gender roles, and contributed to the low self-esteem among Aboriginal males. In addition to esteem, increased rates of alcohol and substance use, depression and suicide were seen in men. Similar rates were also seen in Aboriginal women and attributed to both the cultural changes since colonization as well as socio-economic factors such as family violence (19). Durst (20) attributed the unsettled change in gender relationships and IPV to factors such as the decrease in traditional activities due to industrialization, increased exposure to media, improved transportation, changes in female roles, and financial wealth. To sum up some of these direct colonial impacts, some Inuit families identified precipitators of IPV as economic stress and dependency, disagreement and jealousy, lack of communication between intimate partners, and alcohol and substance use.

Alcohol and substance use Korhonen (19) describes alcohol as a ‘‘fairly recent import’’ to residents of Northern Canada and suggests Arctic people have not developed the rules and rituals for drinking, unlike people from an ‘‘alcohol-adapted culture’’ (p. 37). Alcohol abuse was also suggested as the ‘‘single most important health problem in the circumpolar world’’ relating it not only to health effects but also to family violence (19). As presented in disparate ways within the literature, alcohol use played a role in the perpetration of IPV and violence against women as a root cause, an aggravating factor, or both.


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Many women who experience IPV have histories of substance abuse; alcohol and drug abuse had been linked as both a predisposing and aggravating factor to IPV in Aboriginal communities (21). The increasing availability of alcohol and drug substances paralleled the peaking rates of domestic violence in the Canadian Arctic (3). In 2009, about 65% of IPV victims in the territories reported that their current or former spouse had been drinking during the violent incidents (13). Brownridge (6) acknowledged larger amounts of heavy alcohol consumption and IPV incidents with Aboriginal people, but suggested that this is reflective of a larger macro issue rather than a causeeffect relationship between them.

Effects of residential schooling The residential school experience of Canada’s Aboriginal people has been identified as a contributing factor to IPV (21). The historical exposure to violence, trauma and abuse has created and sustained an intergenerational cycle of violence. As either a witness to violence or having direct experience with it as a child, Aboriginal adults are more susceptible to being a victim or an offender of IPV (22). Preventing Aboriginal children’s exposure to family violence may be fundamental in ending violence among people in Canadian Aboriginal communities (23). Housing inadequacy One critical issue that continuously challenged community response to IPV is housing. Housing inadequacy and overcrowding has been closely linked to IPV in Northern Canada (24). Additionally, residents of rural and remote northern communities had inadequate housing options as well as limits to readily available transportation and specialized services (21). For example, most women experiencing IPV never use shelters and/or find it difficult to afford social housing (24,25). In rural and remote northern communities, the options left for many abused women are either to continue living in their homes under the threat of violence or transfer to safer places in a community away from their families. As a consequence, family violence or IPV had been a major contributing factor to women’s experience of homelessness (24). Help-seeking In general, it is highly unlikely that families report violence that happens within the home or involve resources outside the home with what is usually considered a private matter (7,11). IPV had been underreported in Northern Canada for fear of retaliation by the abuser, financial and social dependence on the abuser, public ridicule, and concerns with the justice system process (11). Deeply rooted to the issue of underreporting is the normalization of violence in Aboriginal families (8). Recent studies on help-seeking rates for IPV in Canada had shown that although Aboriginal women are more likely to be abused by their partners than non-Aboriginal

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women, the rates of help-seeking are similar (26). The likelihood of disclosing experience of IPV was found to be higher in the 1999 Violence Against Women Survey than that in 1993 (27). This changing pattern of helpseeking in women experiencing IPV coincides with increasing efforts to improve the criminal justice activity related to IPV.

Gaps in the justice system In the NT and YK, a civil legislation targeting family violence including IPV was initiated (28). The interventions included removing the offender from the home, permitting the victim to remain in the household with custody of the children, and implementing protective orders to prevent contact between victims and offenders (28). This is a fragmented approach. A deliberation on how women are positioned in society amidst colonialism and within an isolated northern environment with limited resources to endorse these interventions may constitute a more holistic policy direction. Paterson (28) concluded that policy frameworks not only failed to target the structural causes of violence but also scrutinized the behavior of women who experience IPV. In Canada’s northern communities, social and economic conditions directly impact the lives of the residents and indirectly impact justice administration (29). An example of the indirect impact on administering justice is the reality that decision-makers in remote and isolated communities in northern Canada are from different cultural, social and economic background than the residents. There are significant cultural differences between the people in northern communities and those who are administering criminal justice system such as lawyers, probation officers, police, court staff and judges. Moorcraft (30) identified the loss of public trust by women in the YT with the police. Barrett et al. (31) suggested that the historical context of oppression and trauma faced by Aboriginal people negatively affected their interaction with the police and the criminal justice system.

Synthesis of media reports Although media reports may hold certain biases and/or personal opinions, they are a source of information that is useful to examine in terms of occurrences in the North and the response and reaction to these elicited events. Themes from the data include reported murders from IPV, reported assaults and criminal charges, emergency protection orders (EPOs) and awareness campaigns and prevention measures.

Reported murders from IPV Murdered women and children in the past 3 years have accounted for the deaths of 5 women and 2 children in the NT and NU in 5 violent incidents, respectively. The first homicide in this timeframe in 2009 was a Dene woman living in the remote community of Gameti, NT



who was beaten to death by her husband. The perpetrator received a 7-year sentence for manslaughter. The NT Coroners report was released in 2012 with recommendations related to the death (32). Second, on June 13, 2011, an Inuk woman and her 2 young daughters (7 and 2 years) from Iqaluit, NU were found shot dead in their home; her spouse, the perpetrator, then took his own life at the grave of his sister in the local cemetery. Third, on December 19, 2011, an Inuvialuit woman was shot and killed by her partner in Tuktoyuktuk, NT. He then turned the gun on himself and ended his life. Fourth, and most recently, in June, 2012, a Metis woman in Fort Resolution was murdered in a domestic dispute. She went to the Health Centre in medical distress, was medevaced to Yellowknife and then Edmonton where she died. Her partner has now been charged with manslaughter after being found guilty a year previously of threatening her. Finally, in July 2012 in Hay River, NT a man murdered another man and woman. The Dene woman was said to have experienced prior abuse from the killer. The perpetrator had been charged earlier with assault of the victim and had served 30 days in jail. A common theme within these homicide accounts is that there was a history of abuse from the same perpetrator and that a prior criminal record was held.

Reported assaults and criminal charges by partners Although this is not a comprehensive review of the media, there were 15 assaults and criminal charges directly noted to be IPV reported in the Northern newspapers during this period of time. The contexts are varied but do provide descriptions of the nature of IPV in the territories. A few examples of particulars extrapolated from the clippings are included here that suggest that children are sometimes present; substance (drugs and alcohol) is a factor; holiday celebrations may be a factor; the perpetrators were often repeat offenders; weapons can include anything in the near vicinity of the outburst*telephones, fists, feet, knifes, rifles, fire; and in some cases family were called for assistance. The captions are interesting and perhaps sensationalized to grab the reader’s attention. One reporter wrote the following: The woman told police that her spouse had forcibly held her down on a bed and ‘‘at one point forced her eye open’’ said Aitken. The woman crawled into the crib of the couple’s 16-monthy-old son and was holding the child when her spouse tried to pull her out. When he couldn’t, he slapped her across the face. Aitken told the court the man would not allow his spouse to leave or use the phone. She eventually was able to call her family in Inuvik and alert them to the situation. She then ‘‘hid in the bedroom until the police arrive’’ said Aitken. (33)

EPOs The media has also reported both satisfaction and dissatisfaction with EPOs. EPOs have been in place for close to a decade. EPOs were initiated in the NT to provide safety and protection from intimate partner perpetrators by inhibiting their access to their partner where there is evidence of abuse and violence. The RCMP enforces the EPO following judicial authorization. Some reports indicate that women are fearful of RCMP believing that RCMP do not always respond to the immediate needs of women or that when they do there is a prejudiced overtone to the response (30). One man in a public news account claimed that he had been wrongfully named as an abuser (34). A local politician took up the claim that EPOs are ineffective strategies in addressing violence (34). Lyda Fuller, community activist against family violence, asserts that EPOs are making a difference for many women and do decrease violence by restricting access (35).

Discussion The literature on IPV in the NT is scant, which is not unexpected since the location itself is mostly remote and under-resourced. However, it is this very remoteness and scarcity of resources that add to the complexity and the compounded effects that are experienced by families and whole communities who are intimately bound to each other. Although there is not an abundance of literature, researchers have focused on studying the aetiology, attributes, consequences of IPV and gaps in services. This broadens our understanding of some aspects of IPV. For example, knowledge is elucidated to identify influences of colonization, residential school and housing inadequacies on the creation of unhealthy environments. Whereby, violence culminates from suffering and pain too great to bear or where shame and blame become normalized in intergenerational dysfunction. Gaps in the service are also exposed. For example, the mental health needs of a colonized population and underserviced places are notably present but solutions are not readily available or identifiable. Researchers are skimming the surface of the issue as attempts are made to provide explanations of IPV in Northern Canada that lead to concrete efforts to care for residents and manage the effects of IPV. This is not enough. There is a need for a more comprehensive research agenda. It is evident that social determinants of health, for example housing inadequacies, do not act in isolation, rather they are interwoven factors with poverty, unemployment, low literacy, etc. affecting territorial people and contributing to stressful living. In addition, the historical context of colonialism and male-dominated societies has created a volatile and oppressive milieu for women. Since the variables that appear to influence IPV are multifactoral, it is acknowledged that a comprehensive


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approach to both the investigation of IPV and the analysis of the data is required.

Conclusion This study has offered a targeted literature review of IPV in Canada’s NT along with the results of a 3-year media watch. The themes from the published literature are contextually enhancing our understanding of both the IPV experience and the circumstances of those experiences. Colonization, alcohol and substance use, effects of residential schooling, housing inadequacies, help-seeking behaviors and gaps within the justice system are all explanatory to IPV. Media reports provide a perception of events surrounding homicides, assaults and charges to perpetrators as a result of IPV and also describe current interventions, such as EPOs and public awareness campaigns. The synthesis contributes to circumpolar knowledge of IPV. It is important to note that there are existing resources provided in all 3 territories through government departments (victim services, shelters for women), and policing services. The Coalition against Family Violence, led by the NT Status of Women, has been instrumental in influencing policy direction with the government and in public awareness of zero tolerance to violence. Most recently, the Department of Justice in the NT has created a 9-month programme for male perpetrators of violence that is offered through the Healing Drum Society. Education sessions have been offered for police and front-line workers. Narrative therapy sessions are currently provided to assist counsellors. These activities are making a difference to local families. This review illuminates the need for further investigation and action to eradicate violence in the North. Furthermore, the elevated number of IPV incidents indicates the need for establishing healthy relationships essential for healthy families, communities and societies, for productive and fully functioning growth and development, and for civility and peace within our homes and homelands. Finally, we can surmise that if violence were eradicated the environment at all levels (family, community, country) would be more conducive to happy and whole communities.

Acknowledgements This study provides a background to a current project that is investigating the responses to IPV in rural and northern regions of Canada. The authors are part of a 5-year 1 million dollar funded SSHRC/CURA grant that involves academic and community partners from the NT, Alberta, Saskatchewan and Manitoba.

Conflict of interest and funding The authors have no conflict of interest.

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19. Korhonen M. Alcohol problems and approaches: theories, evidence and northern practice. Ontario: National Aboriginal Health Organization; 2004. 20. Durst D. Conjugal violence: changing attitudes in two northern native communities. Community Ment Health J. 1991;27:35973. 21. National Clearinghouse on Family Violence. Aboriginal women and family violence. Ottawa: Public Health Agency of Canada; 2008. 22. Alaggia R, Vine C. Cruel but not unusual: violence in Canadian families. Ontario: Wilfred Laurier University Press; 2006. 23. Dumont-Smith C. Exposure to violence in the home: effects on Aboriginal children. Ottawa: Aboriginal Nurses Association of Canada; 2001. 24. Christensen J. Homeless in a homeland: housing (in) security and homelessness in Inuvik and Yellowknife. [PhD thesis]. Montreal: McGill University; 2011. 25. Du Mont J, Miller K. Countless abused women: homeless and inadequately housed. Can Woman Stud. 2001;20:11522. 26. Hyman I, Forte T, Du Mont J, Romans S, Cohen MM. Helpseeking behavior for intimate partner violence among racial minority women in Canada. Wom Health Issues. 2009;19: 1018. 27. Du Mont J, Forte T, Cohen MM, Hyman I, Romans S. Changing help-seeking rates for intimate partner violence in Canada. Women Health. 2005;41:119. 28. Paterson S. ‘Resistors’, ‘helpless victims’ and ‘willing participants’: the construction of women’s resistance in Canadian anti-violence policy. Soc Polit. 2010;17:15984.

29. Lilles H. Some problems in the administration of justice in remote and isolated communities. Queens Law J. 1990;15: 32744. 30. Moorcroft L. If my life depended on it: Yukon women and the RCMP. 2011. Retrieved from: http://www.womensdirectorate. gov.yk.ca/pdf/rcmp_review_morcrof 31. Barrett BJ, St. Pierre M, Villaincourt N. Police response to intimate partner violence in Canada: do victim characteristics matter? Women Crim Justice. 2011;21:3862. 32. Menard C. NWT coroner’s report. 2012. Retrieved from: http://www.cbc.ca/news/canada/north/story/2012/04/12/northcoroner-report-domestic-violence-nwt.html 33. Loverock C. Man gets jail for Christmas eve assault. Yellowknife, Canada: Northern News Service; 2009. 34. Northern News. Yellowknifer. 2012 Jan 4. Retrieved from: www.nnsl.com/frames/newspapers 35. Northern News. Yellowknifer, 2011 Dec 21. Retrieved from: www.nnsl.com/frames/newspapers.

*Pertice Moffitt Health Research Programs Aurora Research Institute 5004 54th Street Yellowknife, NT X1A 2R3 Canada Email: [email protected]


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BEHAVIORAL HEALTH

Tobacco use prevalence disentangling associations between Alaska Native race, low socio-economic status and rural disparities Julia A. Dilley1*, Erin Peterson2, Matthew Bobo2, Kathryn E. Pickle1 and Kristen Rohde1 1

Program Design and Evaluation Services, Multnomah County Health Department and Oregon Health Authority, Portland, OR, USA; 2Alaska Department of Health and Social Services, Anchorage, AK, USA

Background. Tobacco use rates are exceptionally high among indigenous people in North America. Alaska Native, low socio-economic status (SES) and rural communities are high-priority populations for Alaska’s Tobacco Control program. Design. For the purpose of better informing tobacco control interventions, we conducted a descriptive study to describe high-priority groups using prevalence-based and proportion-based approaches. Methods. With data from 22,311 adults interviewed for Alaska’s 20062010 Behavioral Risk Factor Surveillance System (BRFSS), we used stratified analysis and logistic regression models to describe the current use of cigarettes and smokeless tobacco (SLT) (including iq’mik, a unique Alaska Native SLT product) among the 3 populations of interest. Results. ‘‘Population segments’’ were created with combinations of responses for Alaska Native race, SES and community type. We identified the highest prevalence and highest proportion of tobacco users for each type of tobacco by ‘‘segment.’’ For cigarette smoking, while the largest proportion (nearly one-third) of the state’s smokers are non-Native, high SES and live in urban settings, this group also has lower smoking prevalence than most other groups. Alaska Native, low SES, rural residents had both high smoking prevalence (48%) and represented a large proportion of the state’s smokers (nearly 10%). Patterns were similar for SLT, with nonNative high-SES urban residents making up the largest proportion of users despite lower prevalence, and Alaska Native, low SES, rural residents having high prevalence and making up a large proportion of users. For iq’mik use, Alaska Native people in rural settings were both the highest prevalence and proportion of users. Conclusion. While Alaska Native race, low SES status and community of residence can be considered alone when developing tobacco control interventions, creating ‘‘population segments’’ based on combinations of factors may be helpful for tailoring effective tobacco control strategies and messaging. Other countries or states may use a similar approach for describing and prioritizing populations. Keywords: Alaska/epidemiology; Smoking/epidemiology; Prevalence; Smoking/ethnology; Indians, North American; Tobacco, smokeless

obacco use remains the leading cause of preventable death and disease in the United States and worldwide (1). With each passing year, additional information has become available that describes the health consequences of using tobacco (2); yet, despite this evidence, individuals continue to purchase and use tobacco products. Some recent studies have in particular documented extremely high tobacco use among circumpolar indigenous populations. For example, ChateauDegat et al. measured 84% smoking among Inuit adults in Quebec (3); Egeland, Cao and Young in a separate

T

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study measured 69% smoking among Inuit adults across Canada (4); and the State of Alaska has documented smoking prevalence among Alaska Native adults in excess of 40%, approximately double that of the nonNative population (5). One reason that tobacco continues to be so widely used worldwide is the sophisticated promotion and other marketing approaches used by the tobacco industry, which spent more than $8.5 billion on cigarette and smokeless tobacco (SLT) marketing in 2010 for the United States alone (6). Although the tobacco industry


Tobacco prevalence disparities in Alaska

has far more resources than public health, spending more than $18 to market tobacco products for every $1 spent by states in the United States to reduce tobacco use (7), some approaches used by the industry to promote tobacco products can be studied and replicated at relatively low cost for the purpose of reducing tobacco use. Marketing science has long recognized the value of identifying ‘‘market segments,’’ or profiles of potential customer clusters, who can then be the focus of advertising messages (8). Segmentation is still widely used to market diverse products and ideas (9). Yet, most public health programs describe priority populations only in single terms and underutilize the approach of marketing segmentation to refine and focus delivery of messages to ‘‘population segments.’’ The State of Alaska has successfully implemented a tobacco control effort since 1996 and has observed significant reductions in both adult and youth tobacco use in the general population (10). Alaska Native communities and people with lower socio-economic status (low SES) are examples of high-priority population groups for Alaska’s tobacco control efforts, due to continued high tobacco use prevalence (11). Tobacco use is also higher outside the relatively few densely populated areas in the state, such as Anchorage and Fairbanks (12). These 3 factors (Alaska Native race, low SES status and rural location) are often correlated; for example, Alaska Native people are more likely than non-Natives in Alaska to live in rural communities, and also to be lower income (13). Other factors may also be important to consider when targeting anti-tobacco messages, such as age, employment status and whether children are present in the home. With multiple possible combinations of demographic characteristics that could be considered, leading to potentially unmanageable numbers of ‘‘population segments’’ for targeted intervention, it may also be useful to consider how to prioritize those groups. Prioritization of the largest population groups for interventions may be appealing because of the potential to significantly change statewide prevalence estimates. However, failure to identify and appropriately serve high-prevalence subgroups is likely to aggravate health inequities and is a failure if the program’s mandate is to serve an entire population. Both approaches for identifying priority populations have merit, and approaching prioritization from both lenses can provide the clearest picture of need when planning. Identifying high-priority ‘‘segments’’ may also help to monitor the effect of interventions in different groups, as a contribution to efforts to decrease health disparities. The purpose of this analysis is to define and describe ‘‘high-priority population segments’’ for tobacco control, based both on prevalence of use and proportions of users and to understand more about their characteristics. We used a market segmentation-like approach to describe

different clusters of adult current smokers and current SLT users in the State of Alaska, specifically examining characteristics of Alaska Native race, low SES and urbanrural residence because of their priority for the state program and implications for program design. Findings may be useful for informing tobacco control interventions, including marketing of tobacco cessation messages or cultural adaptation of interventions in the state, and may also provide an example for other states or countries working to deliver tobacco control effectively in diverse community settings with indigenous populations.

Methods Data sources We used data from 22,311 adults interviewed as part of the 20062010 Alaska Behavioral Risk Factor Surveillance System (BRFSS). BRFSS is a CDC-sponsored statewide, random-digit-dial landline telephone survey of adults (people older than 18 years). The survey collects information about a variety of demographic and health factors. Alaska’s BRFSS is administered only in English. Alaska’s BRFSS methods and variables used in this study are consistent with federal guidelines (14). Measures Outcomes: tobacco use A standard BRFSS definition of current smoking status was used (having smoked at least 100 cigarettes during a lifetime, and currently smoking ‘‘every day’’ or ‘‘some days’’). We categorized the smoking outcome as ‘‘current’’ vs. ‘‘non-current’’ use. Current SLT users were similarly classified as ‘‘current’’ for respondents who answered ‘‘yes’’ to the question ‘‘Do you currently use any SLT products such as chewing tobacco, snuff, iq’mik or Blackbull?’’ Current iq’mik users were SLT users who specifically reported using iq’mik (a unique SLT variant prevalent in Southwest Alaska) (15). Demographics Respondents provided their exact age and highest level of formal education completed. They also provided information about total household income (estimated) and whether there were children in the home. Employment status was classified based on self-report as: currently employed (including self-employed), unemployed or not in the workforce (homemaker, student, retired or unable to work). Individuals were classified as ‘‘lower SES’’ if they had less than a high-school education or an income B185% of Alaska’s federally determined poverty level. Alaska Native race was defined based on self-reported single race or preferred race as ‘‘American Indian or Alaska Native’’ (AIAN). We use the term ‘‘Alaska Native’’ in this article, as do most reports and documents for the


223


state, because most AIAN people in Alaska are of Alaska Native heritage (13). Urbanhubrural community residence was determined based on federal classifications using a selfreported home zipcode and telephone prefix. Only the city of Anchorage, the immediate surrounding area, and the city of Fairbanks qualified as ‘‘urban’’ or metropolitan areas. ‘‘Hub’’ (micropolitan) included areas such as municipalities of Juneau and Bethel, which are off the road system but serve as gateways and provide centralized services to smaller villages that surround them. ‘‘Rural’’ areas included hundreds of villages throughout the state, often with only 100500 residents.

Analysis Data were weighted to adjust for sampling design (based on region and telephone listing), and for the number of telephones and adults in each household. Data were also post-stratified to the age and sex distribution of the Alaska State population. Procedures took into account complex sampling design and post-stratification weights. We used Stata 10.1† for all analyses. We used logistic regression models to examine tobacco use prevalence among specific groups, both stratified and adjusted for multiple demographic factors. We used the Stata ‘‘svytotal’’ command to estimate population sizes; this procedure takes into account the weights applied to individual observations in the sample to calculate total numbers in a population. We created 12 ‘‘population segments’’ that represented all combinations of these variables (Alaska Native race: yes/no; lower SES: yes/no; and community type: urban, hub, rural), and used stratified analysis to describe their tobacco use.

Results Tobacco use prevalence for cigarettes, all SLT and iq’mik alone are shown overall and for demographic subgroups in Table I. Cigarette smoking prevalence was 21.3% for the state overall. After adjustment for all other demographic characteristics, most of the identified factors remained significantly associated with higher odds of smoking including male gender, younger age, being unemployed, lower SES or Alaska Native race. Living in hub or rural community settings and having children in the home were not significantly associated with increased odds for smoking after adjustment for other factors. Current SLT use prevalence was 4.9% among the total state population. Being male, younger, Alaska Native, and living in hub or rural settings were all significantly associated with odds for higher SLT use after adjustment for other factors. Iq’mik use prevalence was only 0.7% among the total state population but 4.9% among Alaska Native adults. After adjustment for other factors, being Alaska Native

224

and living in hub or rural communities had extremely large odds ratios for association with the current iq’mik use; being female, having children in the home, and lower SES remained significant for increased odds of iq’mik use also. Table II describes the proportion and numbers of different demographic groups in the state’s adult population, within current tobacco user populations. The highest proportions of the state’s estimated 104,900 smokers were male, aged 3049 years, had children at home, were employed, higher SES, non-Native and living in urban communities. The highest proportions of the state’s estimated 23,100 SLT users were also male, aged 3049 years, had children at home, were employed, higher SES, nonNative and living in urban communities. The state’s current 3,300 iq’mik users were more often female, with children in the home, employed, lower SES, Alaska Native and living in rural settings. There were strong correlations between the 3 key variables of interest, measured using design-based Pearson Chi-square: Alaska Native race and community type (x2 723.2, p B0.001), Alaska Native race and lower SES (x2 689.2, p B0.001), and community type and lower SES (x2 190.1, p B0.001) (data not shown). Alaska Native race, SES and community type were used to create 12 ‘‘population segments.’’ Tobacco use prevalence for each is displayed in Fig. 1 for cigarette smoking and Fig. 2 for SLT use. The top 3 ‘‘population segments’’ for each type of tobacco were identified based on: (1) prevalence of the current tobacco use; and (2) proportion of the current tobacco users (see Table III). For current smokers, non-Native urban residents (both higher and lower SES) represented the largest proportion at over 50% combined. Alaska Native, lower SES adults in all community settings, represented the highest prevalence groups, with more than 40% smoking prevalence in each group. Alaska Native, lower SES adults in rural communities were in the top tier as both highest prevalence and highest proportions of smokers. In these high-priority groups, male gender was generally dominant. Young adults were more represented in urban settings. More than two-thirds of Alaska Native smokers in these priority groups were more likely to have children in the home in all community settings, and about onethird of Alaska Native smokers in priority groups were out of work. Similarly, for SLT users, non-Native, higher SES urban and hub residents made up the largest proportion of users (45% combined), but Alaska Native rural and lower SES hub residents had the highest prevalence of use. Alaska Native, lower SES, rural residents were among the top tier as having both the highest prevalence and proportion. Among non-Native smokeless users, nearly all were male, about half had children in the home, and very few were out of work. Among Alaska Native people who use



Table I. Tobacco use prevalence and odds for tobacco use in specific demographic groups Cigarette smoking

Smokeless tobacco use

Iq’mik use

Adjusted* Alaska BRFSS 20062010 combined

% Smoking (95% CI)

Crude odds Adjusted odds ratio (95% CI) ratio (95% CI)

% use (95% CI)

Crude odds ratio (95% CI)

odds ratio (95% CI)

% use (95% CI)

Crude odds ratio (95% CI)

Adjusted* odds ratio (95% CI)

Total (n 22,311)

21.3 (20.422.2)

4.9 (4.55.3)

0.7 (0.60.8)

Gender: Female

19.5 (18.520.6)

Referent

Referent

1.4 (1.11.6)

Referent

Referent

0.8 (0.61.0)

Referent

Referent

7.0 (5.68.6)

0.6 (0.50.8)

(n12,181) Gender: Male

23 (21.624.4)

(n10,130) Age: 50 or better

16.1 (15.217.2)

1.2 (1.11.4) Referent

1.2 (1.11.4) Referent

8.2 (7.49.0)

(5.38.0)

2.7 (2.33.1)

Referent

Referent

0.5 (0.40.7)

6.2 (5.57.0) 6.1 (5.07.4)

2.4 (1.92.9) 2.3 (1.83.0)

2.0 (1.62.6) 1.9 (1.42.5)

0.8 (0.61.0) 0.8 (0.61.2)

3.6 (3.24.1)

Referent

Referent

0.3 (0.20.4)

6.3 (5.67.1)

1.8 (1.52.2)

1.3 (1.01.6)

1.2 (1.01.4)

5.2 (4.75.8)

Referent

Referent

0.5 (0.40.6)

0.7 (0.51.0) Referent

0.7 (0.50.9) Referent

(n10,437) Age: 3049 (n8,579) Age: 1829 (n3,007)

21.2 (20.022.5) 29.7 (27.132.4)

No children at home

19.6 (18.520.7)

1.4 (1.31.6) 2.2 (1.92.5) Referent

1.4 (1.21.6) 1.8 (1.62.1) Referent

1.6 (1.12.3) 1.7 (1.02.7) Referent

1.1 (0.71.7) 0.9 (0.61.6) Referent

(n13,216) Children at home

23.3 (21.924.8)

(n9,033) Currently employed

19.5 (18.420.5)

1.2 (1.11.4) Referent

0.9 (0.81.0) Referent

4.6 (3.06.9) Referent

2.1 (1.33.2) Referent

(n14,542) Currently unemployed

45.0 (40.949.1)

3.4 (2.84.1)

2.0 (1.72.5)

10.6 (8.513.0)

2.1 (1.72.8)

1.2 (0.91.7)

3.1 (2.34.2)

6.6 (4.59.7)

1.6 (1.02.3)

19.4 (17.821.1)

1.0 (0.91.1)

1.0 (0.81.1)

2.2 (1.73.0)

0.4 (0.30.6)

0.6 (0.40.9)

0.5 (0.30.7)

1 (0.71.6)

0.8 (0.51.4)

4.2 (3.74.7)

Referent

Referent

0.2 (0.10.3)

Referent

Referent

6.9 (6.07.9)

1.7 (1.42.1)

1.1 (0.91.4)

2.1 (1.72.5)

10.8 (7.415.9)

2.1 (1.43.2)

3.7 (3.34.2)

Referent

Referent

Referent

Referent

(n1,565) Currently not in

workforce (n 6.066) Higher SES 16.3 (15.417.3) 34.9 (32.836.9)

Non-Native race

18 (17.118.9)

Referent 2.7 (2.53.1) Referent

Referent 2.1 (1.82.4) Referent

0.00 (0.000.02)

(n17,854) Alaska Native race

41.2 (38.743.7)

3.2 (2.83.6)

2.2 (1.92.6)

12.3 (11.013.7) 3.6 (3.04.3)

2.4 (2.03.0)

4.9 (4.15.7)

1172.3 (242.65665.2) 979 (135.97053.5)

3.4 (2.94.0)

Referent 1.6 (1.32.0)

Referent 1.4 (1.11.8)

0.00 (0.000.02) Referent 0.4 (0.30.7) 132.4 (17.6997.3)

3.5 (2.84.2)

2.4 (2.03.0)

3.9 (3.34.6)

(n4,143) Urban (n8,908)

19.1 (17.920.4)

Hub (n7,018) Rural (n6,379)

22.6 (21.423.8) 29.2 (27.830.7)

Referent 1.2 (1.11.4) 1.7 (1.61.9)

Referent 1.1 (1.01.2) 1.1 (1.01.3)

225

*Model adjusted for all other demographic factors in the table.

5.4 (4.76.2) 10.8 (9.811.9)

Referent 56.4 (7.4432.4)

1217.1 (170.18709.3) 193.1 (26.41412.3)


(n16,209) Lower SES (n6,054)


Table II. Proportions and estimated numbers of tobacco users in Alaska in specific demographic groups Total Alaska adult population

Total

Smokeless tobacco Cigarette smokers

users

Iq’mik users

% population

% users (estimated

% users (estimated

% users (estimated

(estimated number

number in state, rounded



in state)

to nearest hundred)

to nearest hundred)

to Nearest hundred)

100.0%

100.0%

100.0%

100.0%

104,900

23,100

3,300

Gender: Female

48.1%

44.2% 46,300

13.4% 3,100

55.7% 1,800

Gender: Male

51.9%

55.8%

86.6%

44.3%

58,500

20,000

1,500

27.4%

20.0%

26.2%

28,500

4,600

800

40.1%

51.1%

45.6%

41,700

11,700

1,500

Age: 50 or better

36.3%

Age: 3049

40.3%

Age: 1829

23.4%

32.5% 33,800

28.9% 6,600

28.2% 900

No children at home

53.5%

49.2%

40.0%

20.4%

51,500

9,200

700

50.8%

60.0%

79.6%

53,100

13,800

2,600

61.6%

72.6%

48.2%

64,200

16,500

1,500

15.7% 3,600

33.1% 1,100

Children at home Currently employed

46.5% 67.5%

Currently unemployed

7.3%

15.4% 16,000

Currently not in workforce

25.2%

23.0%

11.7%

18.7%

24,000

2,700

600

55.7%

61.9%

20.3%

58,300

14,300

700

44.4%

38.1%

79.7%

46,500

8,800

2,600

72.3% 74,700

64.9% 14,900

0.5% B100

Higher SES Lower SES

72.8% 27.3%

Non-Native race

85.6%

Alaska Native race

14.4%

Urban

66.7%

27.8%

35.1%

99.5%

28,700

8,000

3,200

59.9%

46.4%

0.3%

62,800

10,700

B100

Hub

17.4%

18.5%

19.0%

11.0%

19,400

4,400

400

Rural

15.9%

21.6% 22,600

34.6% 8,000

88.7% 2,900

SLT, about two-thirds were male, about one-third were young adults, more than half had children in the home, and many were out of work. For Iq’mik users, the top tier groups of proportion and prevalence were the same: Alaska Native Rural residents in both SES categories and also Alaska Native lowerSES Hub residents. These groups were more likely to be female, often young adult, most (especially rural) users had children in the home, and many were out of work.

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Discussion The disentangling of different populations, characteristics and approaches to prioritization is difficult. We demonstrated one approach to systematically examine data from several different perspectives: (1) a review of prevalence based on independent and adjusted factors; (2) development of ‘‘population segments’’ based on critical factors; and (3) prioritization of population segments separately based on prevalence and proportion, with



% current cigarette smoking

60 50 40

Alaska Native Race - lower SES

30

Alaska Native Race - higher SES

20

Non-Native Race - lower SES

10

Non-Native Race - higher SES

0 Urban

Hub

Rural

Fig. 1. Current cigarette by population segment, Alaska BRFSS 20062010 combined.

% current smokeless tobacco use

further exploration of demographic characteristics in highpriority segments. This marketing research-like approach identified multiple high-priority population segments for Alaska’s tobacco control program and provided more informative detail than describing priority populations based on single characteristics alone. We first examined prevalence by multiple demographic factors independently, also with adjustment for other factors. This approach helped us to understand which apparently higher rates of tobacco use were potentially explained by confounding of other factors. In fact, the increased odds for cigarette smoking in hub and rural communities did not remain after adjustment for other factors. Potentially, other characteristics of the people living in more rural areas may explain the higher rates of tobacco use. Yet, the fact remains that rates are higher, regardless of why, and thus it is still important to focus specific efforts in these communities since they are unlikely to be reached effectively without specific attention. The use of multiple key factors to describe market segments was useful and provided a clearer picture than any single factor alone. Our analyses centred on Alaska Native race, SES and community type because these were 25 20

Alaska Native Race - lower SES

15

Alaska Native Race - higher SES

10

Non-Native Race - lower SES

5

Non-Native Race - higher SES

0 Urban

Hub

Rural

Fig. 2. Current smokeless tobacco use by population segment, Alaska BRFSS 20062010 combined.

a priori factors that the Alaska’s State Tobacco Control Program was intending to address in their program design. In general, for both cigarettes and SLT, non-Native populations that emerged as high-priority were most often urban, while Alaska Native populations were most often rural and hub. While not suggesting that these associations should be completely exclusive, the data do support developing culturally competent interventions to reach Alaska Native people in more relatively rural settings and non-Native tobacco control in more urban settings. Our findings also suggest that consideration of community setting and Alaska Native race and culture is especially important when planning SLT interventions, illustrated by the dramatic differences in prevalence associated with community type among Alaska Native people. Generally, identifying the highest priority ‘‘population segments’’ using both population size- and prevalencebased approaches did not yield the same results, and provided a richer frame of consideration than either one alone. The largest proportion of both cigarette smokers and SLT users in the state was the non-Native, high SES, urban adult segment. Yet, prevalence of smoking and smokeless use was lower in this segment than most others. On the one hand, focusing efforts in low prevalence segments could be helpful if anti-tobacco community norms make the remaining tobacco users more likely to try quitting. On the other hand, some researchers have theorized that at some point of low prevalence the remaining tobacco users are highly addicted, unmotivated to change, and might be prohibitively expensive or difficult to reach effectively (16). If this occurs, there might be more benefit to deploying resources in higher prevalence communities with fewer, but more motivated tobacco users. Perceived receptivity could be assessed in program planning, for example, by examining recent attempts to quit smoking in the different population segments. Providing demographic descriptions of the high-priority groups was useful in further thinking about development of salient messages and interventions. We saw that Alaska Native people were consistently more likely than nonNative people to have children in the home; therefore, the data suggest that tobacco control efforts tailored to serve Alaska Native people and their families may reach young people, including for tobacco prevention, and when considering this secondary audience the potential benefits of Alaska Native-specific efforts become even greater. In particular, having children in the home was independently associated with SLT use, and this information may be useful for tailoring tobacco control messages, or possibly deserves more study to understand motivations behind use of SLT, such as if adults are switching from smoking to SLT to protect children from second-hand smoke. Also, the high percentage of Alaska Native SLT users who are out of work and very low percentage of non-Native SLT users


227


228 Table III. Highest proportion and highest prevalence tobacco users, with demographic characteristics Tobacco use

Demographic characteristics among users Estimated No. of tobacco

% Current use (95% CI)

% of tobacco-using population

Non-Native, high SES, urban

14.3 (13.115.6)

32.3

Non-Native, low SES, urban

29.7 (26.533.2)

19.0

users (rounded to nearest 100)

% Male

% Young adult (1829)

% With children in home

% Out of work

33,400

54.6

28.1

41.9

7.9

19,600

55.5

42.2

55.9

23.0

Cigarette smokers Highest proportion


Alaska Native, low SES, rural

47.9 (44.851.0)

9.5

9,800

62.2

34.4

69.7

34.6

Highest prevalence Alaska Native, low SES, hub

49.6 (44.554.8)

3.6

3,700

59.5

38.5

64.3

36.6


47.9 (44.851.0)

9.5

9,800

62.2

34.4

69.7

34.6

Alaska Native, low SES, urban

46.4 (37.056.0)

4.8

4,900

45.1

49.7

70.7

30.3

Smokeless tobacco users Highest proportion Non-Native, high SES, urban

3.5 (2.94.2)

34.2

7,800

98.3

26.0

49.4

3.1


22.7 (20.025.7)

18.9

4,300

59.9

28.6

82.4

40.8

4.7 (3.95.6)

10.8

2,500

99.5

22.9

53.6

1.1


22.7 (20.025.7)

18.9

4,300

59.9

28.6

82.4

40.8

Alaska Native, high SES, rural

16.5 (13.620.0)

7.1

1,600

64.0

39.7

70.1

27.1

Alaska Native, low SES, hub

11.6 (8.315.9)

3.5

800

67.6

35.3

65.6

40.8


11.8 (9.914.2)

71.0

2,300

47.1

26.9

84.9

37.2

Alaska Native, high SES, rural Alaska Native, low SES, hub

5.5 (3.97.7) 3.6 (2.26.1)

16.9 7.9

500 300

39.0 45.3

46.4 20.8

80.5 58.4

18.6 49.6

Non-Native, high SES, hub Highest prevalence

Iqmik users Highest proportion and prevalence


who are out of work provides input for design of campaigns to reach either group. Given that resources are generally limited, a focus on broad population-based strategies (including taxes, second-hand smoke bans) that reach all populations is efficient. But within these interventions, attention can be given to tailoring messages and supportive services so that they reach and are effective with high-priority population segments in an appropriate way. Alaska is addressing this by offering community-based grant applicants a set of interventions that show population-wide impact, but also may be uniquely deployed regionally, and asking grantees to describe how they will specifically reach Alaska Native and low SES people, including through systems change in the organizations or structures that serve them. We were able to use the existing surveillance data to apply market research-like approaches without additional costs of data collection. This was an efficient strategy for better understanding populations to serve, although multiple years of data were required to generate sufficient numbers of respondents for robust analyses. However, even if more data were available, quantitative analyses alone cannot provide definitive answers about which people need help the most, and how to reach them. This analysis is an example of providing data in a way that more meaningfully informs the discussion and thinking of program leaders and stakeholders one that can be used by them in combination with other considerations to provide greater opportunities for programmatic successes. Additionally, trends in health factors can be monitored for specific segments, to evaluate the effectiveness of public health efforts.

Limitations Several limitations apply to our study. First, the Alaska BRFSS is limited to adults living in households with landline telephones and who speak English. These respondents may not be representative of the entire population. Second, our classification of current tobacco users did not include frequency, therefore some people that we classified as ‘‘current users’’ could potentially be infrequent or inconsistent smokers or SLT users. Third, some measures that we used to describe individuals (such as SES and urbanhubrural community residence) may misclassify our intended factors having insufficient access to resources and living in increasingly remote locations.

Conclusions While Alaska Native race, low SES status and community of residence can each be considered alone, and tobacco control interventions planned accordingly, our study showed that thinking of ‘‘population segments’’ may be helpful for better tailoring effective tobacco

control interventions. The identification of high-priority population segments based both on prevalence and proportion of tobacco use, with subsequent description by demographic factors, may be useful for program design in countries or regions with mixed community contexts and indigenous groups.


References 1. Centers for Disease Control and Prevention. World No Tobacco Day May 31, 2012. MMWR Morb Mortal Wkly Rep. 2012;61:365. Available from: http://www.cdc.gov/mmwr/ preview/mmwrhtml/mm6120a1.htm 2. US Department of Health and Human Services. How tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2010. 3. Chateau-Degat ML, Dewailly E, Louchini R, Counil E, Noe¨l M, Ferland A, et al. Cardiovascular burden and related risk factors among Nunavik (Quebec) Inuit: insights from baseline findings in the circumpolar Inuit health in transition cohort study. Can J Cardiol. 2010;26:1906. 4. Egeland GM, Cao Z, Young TK. Hypertriglyceridemic-waist phenotype and glucose intolerance among Canadian Inuit: the International Polar Year Inuit Health Survey for Adults 2007 2008. CMAJ. 2011;183:E5538. 5. Alaska Department of Health and Social Services. What state surveys tell us about tobacco use among Alaska Natives: implications for program planning. Anchorage, AK: Section of Chronic Disease Prevention and Health Promotion, Division of Public Health, Alaska Department of Health and Social Services; 2007. 6. United States Federal Trade Commission. Cigarette report for 2009 and 2010. United States Federal Trade Commission. [cited 2013 Jun 20]. Available from: http://ftc.gov/os/2012/09/ 120921cigarettereport.pdf 7. FTC Report Shows Big Decline in Cigarette Sales after 2009 Federal Cigarette Tax Increase, While Tobacco Companies Still Spend Huge Sums on Marketing. Campaign for TobaccoFree Kids. Statement of Susan M. Liss, Executive Director. September 21, 2012. [cited 2013 Jun 20]. Available from: http:// www.tobaccofreekids.org/press_releases/post/2012_09_21_ftc 8. Haire M. Projective techniques in marketing research. J Market. 1950;14:64956. 9. Dowling GR. Market segmentation and targeting. In: The art and science of marketing: marketing for marketing managers. Oxford: Oxford University Press; 2004. p. 169206. 10. Tobacco Prevention and Control Program. A decade of progress: tobacco prevention and control in Alaska FY 20102011. Anchorage, AL: Tobacco Prevention and Control Program, State of Alaska Department of Health and Social Services; 2011. 11. Tobacco Prevention and Control Program. Alaska strategic plan for eliminating tobacco-related disparities 2011 update. Anchorage, AL: Tobacco Prevention and Control Program, State of Alaska Department of Health and Social Services; 2011.


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12. Alaska Department of Health and Social Services. Tobacco in the Great Land, a portrait of Alaska’s leading cause of death, 2012 update. Anchorage, AK: Alaska Department of Health and Social Services; 2012. 13. State of Alaska Department of Labor and Workforce Development. Alaska economic trends. 2013;33. [cited 2013 Feb 4]. Available from: http://labor.alaska.gov/trends/apr13.pdf 14. Alaska Department of Health and Social Services. Alaska’s behavioral risk factor surveillance system. State of Alaska. [cited 2013 Feb 4]. Available from: http://dhss.alaska.gov/dph/ Chronic/Pages/brfss/default.aspx 15. Beltz DN. Tobacco use in rural Alaska and the trampling tobacco project. Alaska Med. 1996;38:245.

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16. Warner KE, Burns DM. Hardening and the hard-core smoker: concepts, evidence and implications. Nicotine Tob Res. 2003;5:3748. *Julia A. Dilley 827 NE Oregon Street, Suite 250 Portland, OR 97232 USA Tel: 360-402-7877 Fax: 971-673-0590 Email: [email protected]



‘‘I only smoke when I have nothing to do’’: a qualitative study on how smoking is part of everyday life in a Greenlandic village Anne Birgitte Jensen1* and Lise Hounsgaard2,3 1

Queen Ingrid’s Hospital, Nuuk, Greenland; 2Institute of Nursing and Health Sciences, University of Greenland, Nuuk, Greenland; 3Research Unit of Nursing, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark

Background. Smoking-related illnesses, such as chronic obstructive pulmonary disease, cardiovascular disease and lung cancer, are common in Greenland. Factors such as age, gender, cigarette use, restricted smoking at home and socio-economic determinants are well-known predictors for smoking and smoking cessation. In 2005, 66% of the adult population in were Greenland smokers, despite widespread smoking cessation campaigns. It is therefore imperative to identify the factors that influence the low levels of smoking cessation to be able to offer cessation interventions of high quality. Aim. To develop knowledge about how smoking forms an incorporated part of a social and cultural context in the daily lives of unskilled residents of a small town in northern Greenland. Design. An ethnographic field study was carried out in 2010, including participant observation, informal conversation with health professionals and semi-structured interviews with 4 smokers (2 women and 2 men). Data were analysed with a phenomenological hermeneutic approach. Results. All informants were daily smokers. During work hours, they smoked fewer cigarettes due to control policy as well as having something to do. At home, they smoke more during leisure time. Having time on one’s hands can be a factor in smokers remaining as smokers. It appears that smokers seem to consider themselves to be stigmatised. This may be one reason for wanting to stop smoking. Smokers ask how to quit and also ask for help to give up smoking with regard to medical treatment for withdrawal symptoms. Serious illness and pregnancy both appear to be triggers to consider giving up smoking. Severe withdrawal symptoms and lack of knowledge about how to give up smoking are barriers to participants achieving their goal. Conclusion. Prevention initiatives should be targeted at all smokers and a smoking cessation service should be developed, where smokers are supervised and receive medical treatment for withdrawal symptoms. Keywords: ethnographic design; Greenland; self-stigmatisation; smoking behavior; smoking cessation; withdrawal symptoms

he number of restrictions on smoking in public and private spaces in Greenland is rising. Despite various smoking cessation campaigns, preventative initiatives including radio campaigns in 2010 and smoking legislation which restricted smoking in public places, 66% of the adult population in Greenland were smokers in 2005. It is therefore imperative to identify the factors that influence the low levels of smoking cessation to be able to offer cessation interventions of high quality. To be able to understand smoking from ‘‘inside’’ in its social and cultural context, an ethnographic field study was carried out to develop knowledge about how smoking is incorporated in daily living.

T

Smoking-related illnesses such as chronic obstructive pulmonary disease and cardiovascular disease are very prevalent in Greenland. Lung cancer is the most common form of cancer, with double the incidence rates of Denmark (1). In Greenland in 20052007, the proportion of adult smokers over the age of 15 was 66% (2), compared to 25% in Denmark (3). The issue of smoking has priority in the government’s public health programme (Inuuneritta), and the stated goal is that, at the end of 2012, only 40% of the adult population will be smokers (4). Between 1999 and 2005, a downward trend in numbers of smokers can be seen compared to 1993, with fewer


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smokers in all social groups. It is, however, the unemployed and unskilled workers who make up the largest group of smokers (7080%) (2). More men than women give up smoking. A population survey from 1993 shows that there are more smokers in villages than in towns (2). Unlike Denmark, Greenland has experienced a decline in smokers’ average cigarette consumption (from 1993 to 2005) from 11.2 to 9.2 per day, whereas in Denmark there was an increase in the average cigarette consumption per capita until 2007, when a downward trend was seen (5). This may suggest that Greenlanders handle their knowledge about smoking differently than Danish smokers. Since 1995, various smoking reduction measures have been implemented. There are heavy tax duties on tobacco and cigarettes. Smoking laws have restricted smoking in the workplace. There is a total ban on smoking in public buildings and in children’s and educational institutions. There are health warnings printed in Danish and Greenlandic on all cigarette and tobacco packets. There is a ban on the sale of tobacco products to people under the age of 18, and a number of smoking cessation counsellors have been trained (4). On 1 October 2010, the smoking legislation was further tightened to prohibit smoking indoors in all public and private places such as restaurants, cafes, private clubs and associations.

Aim The aim of the study was to develop knowledge about how smoking forms an incorporated part of a social and cultural context in daily lives of unskilled residents of a small town in northern Greenland. The study explored 2 main questions: (a) What significance do smokers attach to smoking in everyday life and (b) How do smokers integrate the public and private smoking rules into their smoking behavior.

Material and method An ethnographic method incorporating interviews, participant observation and informal conversation with an approach based on the understanding that knowledge is something that is created between people through observation and participation in everyday life (6,7). Participant observation along with informal conversation with nurses, a doctor at the hospital and random passers-by in the village where the first author met other smokers were important, since culture cannot easily be discussed directly and objectively by respondents who are living it and making their lives work on a practical level (6). Field notes recorded the first author’s movements in the small fishing village in northern Greenland in June 2010 for 5 weekdays, during which people’s smoking habits were observed. A small village was included because more smokers live in villages than towns and cities. Unskilled workers with a maximum of 9 years

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of elementary school were chosen for interviews because they make up the largest group of smokers (2). Four people were interviewed in depth. Two men and two women who met the following criteria: ethnic Greenlander (at least one grandparent is Greenlandic), aged 3059 years, daily smokers and without chronic diseases attributable to smoking. Access to the smokers was facilitated by the local doctor, who identified potential participants. The first author did the interviews, with 3 taking place in Danish and 1 in Greenlandic that was translated into Danish by a professional translator.

Ethics The project was conducted in accordance with the Declaration of Helsinki, Article II. Written information consent was obtained. The Research Ethics Committee for Scientific Research in Greenland approved the study.

Analysis A phenomenological hermeneutic interpretative approach was taken to data analysis, based on the approach described by Ricoeur (8) and further developed by Scandinavian researchers (9,10). Material from interviews and participant observations were transcribed and analysed. Ricoeur describes the interpretation of a text as an on-going dialectical movement between explanation and understanding. To understand a text is to follow its movement from significance to reference: from what it says to what it talks about. The interpretation method involved 3 analytical steps: naive reading, structural analysis and in-depth understanding (8). The naive reading aimed to be nonjudgmental and to open up insight into the meaning of the text as a whole. A structural analysis was conducted in order to explain the text and to identify and formulate themes. As is apparent from Table I, this step took the form of a movement between units of meaning and units of significance in the text leading towards in-depth understanding. Critical interpretation aimed to develop a new understanding. The interpretation process drew out full sentences and meaning-laden expressions that relate to experiences of smoking, both from the interview text and the field notes from participant observations. These are interpreted and discussed below based on theory and other relevant research.

Results In a movement between units of meaning (what is said/ quotations) and themes (what is being talked about), the structural analysis identified 4 themes: smoking behavior, withdrawal symptoms, smoking cessation and stigma.


How smoking is part of everyday life in a Greenlandic village

Table I. Results of the structural analysis Units of meaning (What is said)

Units of significance (What is being talked about)

Themes

‘‘I smoke when I don’t have anything else to do’’

How smoking is part of daily life

Smoking behavior

‘‘I get restless . . . don’t know what I should be doing’’

Physical and psychological feelings on giving up

Withdrawal symptoms

‘‘I would like to give up smoking, but I don’t know how’’

smoking Lack of knowledge about help to stop smoking

Smoking cessation

‘‘I’ve promised my children I’ll give it up’’

Bad conscience about continued smoking

Stigma

In the following discussion, the 4 themes are presented separately for clarity (see Table I), but with the understanding that they interact with each other in reality.

the four informants said that coffee and a cigarette go together.

Smoking behavior

All the participants knew someone who did not smoke. Three had quit smoking for a period of time ranging from 3 months to a year. They all reported a need for smoking cessation. One informant had just been hospitalised with a heart condition. In the hospital, she was advised to give up smoking, but asked us ‘‘how do I stop?’’ and later added ‘‘but I don’t have any guidance . . . there should be ads on radio and TV about how to quit.’’ Another interviewee said: ‘‘I think you can help me to give up smoking’’. This interviewee also received advice while in the hospital to give up smoking, and responded positively to the idea. One participant had attempted to quit smoking along with her partner for 3 months. It was during a period where her mother-in-law was seriously ill. They took up smoking again because they found that quitting smoking made them angry towards each other and other people. Two participants had also considered stopping smoking, as they were ill or had close relatives who were ill. One informant reduced her cigarette consumption from 15 to 10 cigarettes a day after a period of illness. She tried to buy nicotine gum to help her to stop, but she said it tasted nasty and she got severe headaches, so she only took 2 pieces The informant who does not want to give up smoking said: ‘‘I have tried to skip [the last cigarette] before I go to bed, but I can’t.’’ Later she described why: ‘‘I cannot sleep when I don’t have that last cigarette.’’ She would like to stop if her partner also stopped. The other participants also expressed that they would like to stop together with their partners, and they all expressed that they need help to quit.

Smoking was described as a habit by all 4 participants. Three described smoking as something negative: ‘‘A bad habit in the morning, as soon as I come down, although I don’t want to’’ and another informant, who generally smoked a pipe but smoked cigarettes when he drinks beer, said: ‘‘Unfortunately, I just do it, I’m a robot.’’ The wife of one informant, who was the only person at her workplace who smoked, stated: ‘‘I have a bad conscience. When I smoke at work, I wash my hands, brush my teeth, and chew gum.’’ In addition to it being a habit, for 3 of the 4 participants smoking was also associated with a bad conscience (i.e. feelings of guilt). The participants smoked between 4 and 15 cigarettes a day and had been smoking for at least 20 years. Their spouses smoked too. The participants smoked more when they drank alcohol. ‘‘When I need beer, I start to smoke early in the day.’’ An informant who generally smoked a pipe, except for once or twice a month when he drinks alcohol and shares about 4 packs of cigarettes with friends, said: ‘‘If I stop smoking, I feel better within myself. I have strength of character, and can then stop drinking.’’ The informant indirectly indicated that he has a drinking problem. The participants did not smoke so much when they were working, but rather when they relax or ‘‘are bored’’. One Informant stated: ‘‘I smoke when I don’t have anything to do, so I smoke a cigarette every 1 to 1.5 hours, mostly at the weekend.’’ Another informant said: ‘‘When I’m busy I don’t smoke, it’s mostly when I’m relaxed.’’ And a third stated: ‘‘I forget to smoke when the grandkids are here, when I think of smoking, I just go outside.’’ The participants smoked less at work in part because it must fit into their work schedule. ‘‘I smoke when I’ve completed a big task and after breaks.’’ Another informant told us: ‘‘At work I smoke when others invite me out to smoke, but not every time . . . it has to fit in.’’ Similarly, at home they smoked when they finished something. ‘‘I smoke after work, when I have eaten dinner, when I watch TV, and just before I go to bed.’’ Two of

Smoking cessation

Withdrawal symptoms When it comes to giving up smoking, it was the withdrawal symptoms that occupied all participants. One made the comment that: ‘‘We were shaking and needed a cigarette. Instead we should have gone for a walk . . . What prevents us giving up smoking is all the sulking . . . that period where you get mad at each other . . . we’re afraid of all the negativity towards each other and towards others.’’ Another informant said: ‘‘When I stopped for a week,


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I got restless, did not know what to do, and when I drink coffee . . . I get angry as well . . . how do I stop? I need guidance.’’

Stigma Many years prior to the study, all the informants had themselves implemented smoking restrictions in their own homes, and 3 interviewees have been in that situation for the last 1517 years. Smoking restrictions had begun when they had children. Only one of the subjects never smoked inside, which meant less smoking in bad weather. The other 3 smoked in the living room, but if children or non-smokers were visiting they smoked in the kitchen under the extractor fan, behind a closed door, or even outside. One middle-aged, female Greenlander, who has lived in Denmark for many years, was on holiday and smoked on the street. She thought that the smoking restrictions are excessive: ‘‘It was cosier in the 1970s, when we smoked indoors.’’ They were all characterised by experiencing guilt about smoking, and one was even bullied at work, where she was the only person who smoked. All participants said that the reason they smoked less at work was because they had something to do, and none mentioned that the reduction was due to workplace smoking restrictions.

Discussion The smokers expressed that they smoked the most when they were free from work and did not have anything else to do. Tulenius found that Danish smokers smoke more in ‘‘quiet times’’, but when in the Danish context spoke of ‘‘quiet times’’ it was when interviewees gave themselves time during a stressful working day (11). The participants in this study did not talk about having had a stressful working day. Three of the 4 participants expressed that having a ‘‘good time’’ was essential for them. This was expressed by the fact that they wake up well before they go to work (between the hours of 4:30 and 6:30 am), that it was important that meetings occurred on time, and that the day started quietly. Warming and others wrote about this ‘‘good time’’ in a previous research project on Greenland values in child rearing, now expressed by a participant: ‘‘That his parents took it that you came in good time before you had to be there, as a good upbringing’’ (12). The value ‘‘good time’’ combined with the fact that each smoker smokes most when they have ‘‘good time,’’ may be a barrier for smoking cessation. In connection with having children, the participants had introduced smoking restrictions at home to prevent their children being exposed to the harmful effects of cigarette smoke. The participants have set up smoking restrictions in their own homes in the same time as the political systems starts to make restriction for smoking in public places, which can be seen as an acceptance of the political restriction. None of the responders question the political

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restrictions. It also seems that if close relatives are seriously ill, the participants consider giving up smoking; however, withdrawal symptoms present a barrier to cessation. The value system surrounding human interaction in Greenland is based on placing great emphasis on the need to maintain harmony. The desire to quit smoking among informants from a small town can therefore be set in relation to the Greenlandic desire for harmony in daily life. Warming et al. examined the value system that underlies how children are brought up in Greenland. It points to a situation where: Harmony is still a high priority in villages. A majority of those interviewed indicate that it will benecessary to downplay the desire and the need to always live in harmony. This was necessary in earlier societies, but in modern society, it would be desirable and necessary that young people learn to stand up and speak their minds, to come up with proposals to solve any social problems and to propose changes even if these suggestions may be controversial and go against other people’s perceptions. (12)

The fear of aggression is also described by Rønsager in Greenlanders’ health and illness beliefs spanning over the period 18001930: Historically, traditional societies in Greenland have been small, meaning that unity among community residents was important for survival . . . The small community was therefore vulnerable to people who were different, those who could become aggressive, but also people who were mentally fragile. It was prudent to avoid conflicts, but this was not always possible. There were several ways to resolve conflicts, and common to them all was a low level of aggressiveness. (13)

Harmony value systems prevailed for many years as a key to survival in the small Greenlandic communities. The interviewees were all of an age that made it likely that they had grown up with a desire for harmony. This could be 1 reason why withdrawal symptoms occupied their minds so much. There has also been an international focus on withdrawal symptoms in relation to smoking cessation, including in a meta-analysis by Etter et al., who investigated the long-term effects of smoking cessation using nicotine replacement therapy (NRT). Those who received NRT were significantly twice (OR: 1.99) more likely to be smoke free than the control group receiving placebo (14). Three of the current participants wanted to stop smoking, had experienced smoking cessation, but failed in remaining abstinent. They asked for help to quit smoking. Etter et al. raised the question of whether smoking cessation should be looked at as a chronic disease instead of as an infectious disease with continued treatment (13).


How smoking is part of everyday life in a Greenlandic village

The smokers interviewed were affected by pangs of conscience. One participant was bullied at work for being the only smoker. At the same time there seems to be ambivalence about smoking: the participants continued to smoke despite the fact that they had a bad conscience about being a smoker. The interviewees all knew people who had stopped smoking or who had never smoked. Smoking could be considered as a normative behavior in Greenland since two-thirds of the population currently smoke (2). Three informants want to give up smoking, but this is hampered by aspects of their lifestyle such as seeking harmony in their community. The Danish philosopher, Juul Jensen, describes the power of different ways of life and society’s moral responsibility: ‘‘You can become subject to the power of a way of life by taking its routines and patterns for granted’’ (15). The desire for harmony at all costs when seen as a way of life with this kind of inherent power persists in Greenland and hampers smokers’ attempts to quit smoking. From the perspective of Juul Jensen, it is society’s responsibility that smokers are stuck in the old values of harmony, and based on society’s duty to care for the smokers, one can say that society has a responsibility to help weak smokers to stop. In Greenland, where two-thirds of the adult population are smokers, it seems that by virtue of smoking restrictions, society and non-smokers have created a message to smokers that the ‘‘norm’’ is to belong to the third of the population who do not smoke. Based on Goffmann’s definition, one can say that smokers have become stigmatised: Stigma is something experienced by an individual who, for one reason or another, is not able to achieve full social acceptance. The person is reduced in the collective consciousness from being an ‘‘ordinary’’ person to being an ‘‘impaired and undermined’’ person by being branded with or assigned a ‘‘stigma’’. When a person is branded with a stigma, this simultaneously reaffirms ‘‘the others’’ normality. (16)

Another reason why smokers feel stigmatised could be that their knowledge about the harmful effects of smoking gives them a bad conscience about not having the strength of character to stop. In this way they can self-stigmatise themselves. This experience of stigma can be the underlying reason for their wish to give up smoking. One of the informants tried to buy nicotine replacements, but the packaging indicated that it was too high a dose compared with her cigarette consumption, so she stopped using them because of this discrepancy. The first author checked out the supply of nicotine replacements in the local shop. It was noted that it was only possible to buy nicotine chewing gum, and then only in its strongest dose. One local medical secretary, who has been trained as a smoking cessation trainer, has

not yet set up any cessation courses, and the local council’s prevention consultant focuses mainly on young people who are sniffing glue and on the prevention of suicide. In summary, there is a desire to stop smoking, but withdrawal symptoms form a barrier, and help to stop smoking is requested but is not easily available.

Conclusion The study illustrates that smokers have a lot of time on their own when they are free from work, and it is then that they are most likely to smoke. A disjuncture can also be seen between the desire to quit smoking and the knowledge, will, and strength required. The social and cultural context also impacts the low degree of smoking cessation. Official smoking restrictions have led to nonsmokers being regarded as the ‘‘norm,’’ despite the fact that the majority of the adult population smokes. This implies that there is a process of self-stigmatisation of smokers. The emphasis on achieving and maintaining harmony in relation to those around you seems to be crucial. It appears to create a barrier that prevents smokers giving up smoking when they experience withdrawal symptoms that threaten the harmonious atmosphere. Withdrawal symptoms and lack of knowledge about how to stop are barriers to reaching their goal.

Perspectives One action which could increase the number of nonsmokers would be the establishment of smoking cessation services adapted to the Greenlandic culture, taking into account the values of harmony and having good time. Smokers would be given guidance on, for example what can be used instead of cigarettes and where knowledge and medical treatment of withdrawal symptoms are readily available.


References 1. Bjerregaard P. Folkesundhed i Grønland. INUSSUK [Public Health in Greenland]. Arktisk forsknings journal. 2004;1: 6079. 2. Bjerregaard P, Dahl-Petersen IK. Befolkningsundersøgelsen i Grønland 20052007 [The population survey in Greenland 20052007]. København: Statens Institut for Folkesundhed; 2008. p. 12939. 3. Kjøller M, Juel K, Kamper-Jørgensen F. Folkesundhedsrapporten, Danmark 2007 [Public Health Report Denmark, 2007]. København: Statens Institut for Folkesundhed; 2007. p. 221 34. 4. Greenlands Hjemmestyre. Inuuneritta Folkesundhedsprogram. Landsstyrets strategier og ma˚lsætninger for folkesundheden 20072012 [‘Inuuneritta’, Public Health Program.


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5.

6. 7.

8.

9.

10.

11.

Strategies and targets for public health 20072012]. Nuuk: Grønlands hjemmestyre; 2007. Forbrug og salg af alkohol og tobak pr. indbygger efter type 20052007 [Consumption and sale of alcohol and tobacco per capita for 20052007]. Danmarks statistik; 2008 [cited 2013 June 06]. Available from: http://www.statbank.dk Spradley J. Participant observation. USA: Harcourt Brace Jovanovich College Publishers; 1980. p. 2684. Hastrup K. Det antropologiske projekt om forbløffelse [The anthropological project on amazement]. København: Gyldendal; 1992. Ricoeur P. Fra text til handling En Antologi Om Hermeneutik [From text to action. An anthology of hermeneutics]. Lund: Symposion Bokforlag; 1988. Dreyer P, Pedersen BD. Distanciation in Ricoeur’s theory of interpretation: narration in a study of life experiences of living with chronic illness and home mechanical ventilation. Nurs Inq. 2009;16:6473. Lindseth A, Norberg A. A phenomenological hermeneutical method for researching lived experience. Scand J Caring Sci. 2004;18:14553. Tulinius C. Vi bliver ved med at ryge hvorfor? [We continue to smoke why?]. København: Ma˚nedsskrift for praktisk Lægegerning; 2000. p. 12336.

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12. Warming O, Zøllner L. Er tra˚den bristet? [Is the thread broken?]. Vejle: Kroghs Forlag; 1992. 13. Rønsager M. Grønlændernes sundheds- og sygdomsopfattelse 18001930 [Greenlanders’ perceptions of health and illness 18001930]. København: Statens Institut for Folkesundhed; 2002. 14. Etter JF, Stapleton JA. Nicotine replacement therapy for long-term smoking cessation: a meta analysis. Tob Control. 2006;15:2805. 15. Juul Jensen U. Moralsk ansvar og menneskesyn [Moral responsibility and view of human nature]. København: Munksgaard; 1991. 16. Goffman E. Stigma. København: Gyldendals Boghandel, Nordisk forlag; 1975/1963.

*Anne Birgitte Jensen Department of Medicine Queen Ingrid’s Hospital 3900 Nuuk Greenland Email: [email protected]



High prevalence of medicine-induced attempted suicides among females in Nuuk, Greenland, 20082009 Lars Heymann Bloch1*, Gitte Hansen Drachmann2 and Michael Lynge Pedersen2 1

Dronning Ingrids Hospital, Nuuk, Greenland; 2Primary Health Care in Nuuk, Nuuk, Greenland

Background. The suicide rate in Greenland, especially among men, is among the highest in the world. Attempted suicide rates may be high also. However, the rates of attempted suicide are unknown. Objective. We aimed to estimate the age- and gender-specific incidence of attempted suicide using medicine in Nuuk in 20082009. Design. An observational retrospective study of consecutive medical records on patients admitted to Dronning Ingrids Hospital in Nuuk in 20082009 with possible medicine intoxication. Results. Seventy-four (60 females and 14 men) cases of attempted suicide using medicine were included. Of those, 43 used paracetamol alone or in combination with other medicine. The incidence of attempted suicide using medicine was higher among females than males (p B0.001). The highest incidence of attempted suicide with paracetamol was found among women aged 2024 years (0.84%). The highest incidence of suicide with medication (1.31 per 100 inhabitants per year) was among women aged 1519 years. Conclusions. The incidence of attempted suicide using medicine was high in Nuuk, Greenland, especially among women. The highest incidence of suicide attempts with medication was observed among women in the age group 1519 years (1.31%). This may reflect psychosocial vulnerability among young people in Greenland. Initiatives to improve living conditions for children and adolescents are highly recommended to be initiated immediately. Keywords: paracetamol; alcohol problems; sexual abuse; neglected children; psychosocial problems; vulnerability to emotional stress; emotional crises

reenland is a modern society, with approximately 56,000 inhabitants distributed in 18 cities and a number of small human settlements (1). About one third of the population lives in Nuuk (1). Over the last 60 years, there have been some huge changes, where Greenland has gone from being a traditional Inuit hunting society to a modern society with the majority of the population living by wage income (1,2). In the wake of this rapid cultural and social change, there have been considerable changes in living conditions and health conditions (27). Infectious diseases have declined markedly, while cardiovascular diseases, suicide and alcoholism have increased (5). Mental problems are thus increased in parallel with the societal development (6). The incidence of suicide in Greenland is among the highest in the world (3,8). The highest incidence is found among men aged 1524 years with annual instalments of 0.450.5% (3). The incidence is approximately four times

G

higher for men than for women in Greenland (3). There are also regional differences within Greenland. The highest suicide rate is located in the capital Nuuk and in Eastern Greenland (9). Not all suicide attempts result in death, which is true regarding medicine-induced attempts. It is possible that the incidence of medicine-induced suicide attempts is high among Greenlanders, but it is yet unknown. The purpose of this study is to estimate the prevalence of medicine-induced attempted suicides in Nuuk in the period 20082009 by review of all measured serumparacetamol values and the medical record for all the patients who had their serum-paracetamol measured. Incidents are shown for both genders and a comparison is made with data from other Northern regions (women).

Materials and methods Patients admitted to Dronning Ingrids Hospital who were suspected of medicine-induced suicide attempts were


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reviewed between 2008 and 2009. The standard procedure for patients is to be brought to the emergency room and hospitalized from there. In the case of suspected medicine-induced attempted suicide, a serum-paracetamol (acetaminophen) is measured. This might not be the case for the minor hospitals on the coast. Due to geographic challenges and weather conditions, it is not always possible to get samples transported to Dronning Ingrids Hospital in Nuuk. All patients in the period 20082009 who were tested for serum-paracetamol, were identified by an electronic search of the laboratory system on Dronning Ingrids Hospital. An electronic query was made regarding every measured parcetamol value from 2008 to 2009. By reviewing medical records of the patients who tested positive for paracetamol, only those who resided in Nuuk were included in this study. Medical record information regarding residence, age, sex, alcohol, intoxication, reason for the intake of the medicine, and which type of medicine, were collected. Patients who stated that they had taken medicine as an attempted suicide, were recorded as cases with medicine-induced suicide attempts. Patients who stated that paracetamol was among the medications ingested were recorded as cases with paracetamol-induced suicide attempts. Those who either consumed alcohol, or who were described as alcohol intoxicated in their medical record, were defined as having been drunk, despite serum-ethanol levels not being measured. The age- and gender-specific incidence of medicineinduced suicide attempts was calculated in relation to the background population in Nuuk on 1 January 2009 (1). Ninety-five percentage confidence intervals (CI) were used in this study. Incidences were compared using a Chi-square test with a significance level of 0.05. We have been authorized by the Danish Authorities ‘‘Datatilsynet’’ to collect data. Our data have been anonymized, with identification of individuals no longer possible.

Results During the period 20082009, a total of 135 patients (96 women and 39 men) had their serum-paracetamol measured in the central laboratory in Nuuk. Of the 135 patients, 37 were excluded (23 women and 14 men), as they lived outside Nuuk. Of the remaining 98 patients, 24 patients were excluded (13 women and 11 men), as they had not taken medicine as a suicide attempt. A total of 74 patients (14 men and 60 women) were counted as cases with medicine-induced suicide attempts. Of these, 43 patients (8 men and 35 women) had taken paracetamol as a part of the medication. The prevalence of suicide attempts with medication was higher among women than among men (pB0.001).

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Alcohol intoxication was observed among 61% (45/74) of all cases of suicide attempts with medication. The annual age- and sex-specific prevalence of suicide attempts with medication is shown in Fig. 1. The highest incidence was observed among women in the age group 1519 years (1.31%). There is an increase in cases of suicide attempts with medicine in women age groups 4044 years and 4549 years. The women older than 40 were in 89% (24/27) of cases assessed at admission to be alcohol intoxicated. The annual age- and sex-specific prevalence of suicide attempts with paracetamol is shown in Fig. 2. The highest incidence is found among women aged 2024 years (0.84%). Paracetamol was most frequently used by the 2024 years age group. For this group, paracetamol was used in 77% (10/13) of suicide attempts with medication.

Discussion This study shows that suicide attempts with medication (Fig. 1) is very high in Nuuk, Greenland, especially among women. Prevalence of 1.31% in the women age group 1519 years is the highest incidence described. Young Greenland men have the world record in suicides, nearly twice as high compared to other arctic countries (10). The pattern, showing young women who attempts to commit suicide with medicine, is similar to the pattern in other countries such as England and Wales. The very high prevalence of 1.31% of suicide attempts with medication in women aged 1519 years (Fig. 1), as well as 0.60% in the same age group in which paracetamol has been among the medication (Fig. 2), is surprisingly high in comparison with England and Wales, where admission due to paracetamol poisoning in the 15- to 24-year-old women was 213.09 per 100,000 in 19952002 (0.21%). Figures from 2000 from Fyn in Denmark show an incidence of suicide attempts for young women in the age group 1519 years, at 553 per 100,000, i.e. 0.55% (11). However, there is no information about how the young women have attempted suicide. In Northern Quebec, Canada, a study of 99 Inuit between 14 and 25 years shows that 34% of these have previously attempted suicide. Thirteen percentage of these suicide attempts resulted in hospitalisation. Risk factors here are in the form of physical abuse and alcohol problems in the family (12). Previous studies in Greenland show that 82% of those who have been exposed to frequent alcohol problems as well as sexual abuse have had serious suicidal thoughts (2,10). In relation to pure alcohol problems at home, the suicide thoughts will double in those cases where there has been sexual abuse (2,10). Correlation with education, profession, and socio-economic conditions was not significant (10). This indicates that in Greenlandic society, a


High prevalence of medicine-induced attempted suicides

Females

1,4

Males

1,2

Percent

1 0,8 0,6 0,4 0,2 0

15–19

20–24

25–29

30–34 35–39 Age (Years)

40–44

45–49

50+

Fig. 1. Incidence of medication-induced suicide attempts in Nuuk 20082009 by age group and gender.

significantly increased focus on the conditions for the children and young people is needed, especially in regard to alcohol problems at home and sexual abuse. Many appear to come out of the childhood and youth cases with significant mental health problems, which have emerged due to failure from caretakers. A review of the medical files shows that in many cases, shortly before the suicide attempt, there were emotional crises caused by relationship issues, domestic quarrels, etc. This suggests general vulnerability to emotional stress, which is often seen among neglected children and young people (11). The availability of over-the-counter drugs could also be a subject for improvement. Bjerregaard et al. looked at the incidence of admissions with paracetamol overdose in England and Wales, after the countries reduced the package size. The study showed a 24% reduction in

paracetamol overdose admissions from 1997 to 2002 (13). Paracetamol is already sold in relatively small packet sizes in Greenland, so a reduction in packet size would probably not have a significant impact. However, there could be a requirement that over-the-counter drugs should be sold only by persons above 18 years, and that the seller must have a little knowledge about the medicine. In our study, however, we did not focus on how the drug was acquired. In several cases, the medical records show that there were suicide attempts with combined intoxication with several different types of prescription medicine. A weakness in our study should be mentioned. We have worked with small figures and in case of misinterpretation or randomness, it can give relatively large fluctuations on the results. However, a strength in the study Females

0,9

Males

0,8 0,7

Percent

0,6 0,5 0,4 0,3 0,2 0,1 0

15–19

20–24

25–29

30–34 35–39 Age (Years)

40–44

45–49

50+

Fig. 2. Incidence of paracetamol-induced suicide attempts in Nuuk 20082009 by age group and gender. Citation: Int J Circumpolar Health 2013, 72: 22447 - http://dx.doi.org/10.3402/ijch.v72i0.22447

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is that all measured serum-paracetamol values in 2008 and 2009 are assessed together with the medical records. After exclusion of samples from the coast, a review of the medical records of the patients admitted from general health care was made.

Conclusion The presence of medicine-induced suicide attempts is very high in Greenland, especially among young women. Comparing the incidence of suicide attempt with paracetamol in Nuuk with England and Wales shows that the incidents are significantly higher. For the group of 1524-year-old women, the figures were 0.21% for England and Wales, compared with 0.60% for Nuuk women in the age group 1519 years and 0.84% for the age group 2024 years. The same result arises when comparing the incidence of suicide attempt with medicine in Nuuk with Fyn, Denmark. In the age group 1519 years, the incidents of suicide were 0.55% in Fyn and 1.31% in Nuuk. This indicates significant psychosocial problems in this group of young women in Greenland. A fundamental approach to all facets of children and young people’s lives, including family living, institutional and school relations, is required immediately.

Acknowledgement

3. Bjerregaard P, Lynge I. Suicide a challenge in modern Greenland. Arch Suicide Res. 2006;10:20920. 4. Curtis T, Kvernmo S, Bjerregaard P. Changing living conditions, life style and health. Int J Circumpolar Health. 2005; 64(5):44250. 5. Bjerregaard P, Young TK, Dewailly E, Ebbesson SO. Indigenous health in the Arctic: an overview of the circumpolar Inuit population. Scand J Public Health. 2004;32(5):3905. 6. Bjerregaard P. Rapid socio-cultural change and health in the Arctic. Int J Circumpolar Health. 2001;60(2):10211. 7. Bjerregaard P, Curtis T, Greenland Population Study. Cultural change and mental health in Greenland: the association of childhood conditions, language, and urbanization with mental health and suicidal thoughts among the Inuit of Greenland. Soc Sci Med. 2002;54(1):3348. 8. Grove O, Lynge J. Suicide and attempted suicide in Greenland. A controlled study in Nuuk (Godthaab). Acta Psychiatr Scand. 1979;60(4):37591. 9. Bjerregaard P. Geographic variation of mortality in Greenland. Economic and demographic correlations. Arctic Med Res. 1990;49(1):1624. 10. Bjerregaard P. Selvmord og selvmordstanker I Grønland. Nuna Med 1997 s. 14246. 11. Zoellner L. Center for selvmordsforskning. Nordisk Psykologi. 2002;54(4):287300. 12. Kirmayer LJ, Malus M, Boothroyd LJ. Suicide attempts among Inuit youth: a community survey of prevalence and risk factors. Acta Psychiatr Scand. 1996;94(1):817. 13. Morgan O, Griffiths C, Majeed A. Impact of paracetamol pack size restrictions on poisoning from paracetamol in England and Wales: an observational study. J Public Health (Oxf.) 2005;27(1):1924.

The authors thank Chief lab Technician Inge Lise Kleist. *Lars Heymann Bloch Email: [email protected]

References 1. Greenlands Statistic. Available from: www.stat.gl 2. Bjerregaard P, Young TK. The Circumpolar Inuit: health of a population in transition. 1st ed. Copenhagen: Munksgaard; 1998.

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Coordinating foetal alcohol syndrome interventions in Alaska Kris Broom, Wendy Getchell, Chantelle Hardy, Garrett Hartley* and Jessica Olson UNC School of Public Health, Chapel Hill, NC, USA

Introduction Foetal alcohol syndrome (FAS) is a preventable cause of lifelong mental disability. Although the prevalence of FAS/Foetal Alcohol Spectrum Disorders (FASD) has decreased, Alaska continues to have the highest incidence of FAS in the US with rates higher among Alaska Natives than non-natives (Fig. 1). Annual FAS costs for Alaska, in 1988 were projected to be more than $11.1 million (1).

Objectives To review current Alaska FAS policies and interventions, and to identify successful FAS interventions in the circumpolar region for implementation in Alaska.

Materials and methods We conducted a literature review using PubMed and Google Scholar, and an Internet search, for the period January 2000December 2012, to identify FAS interventions in Alaska and the circumpolar region. Internet search engines used were Google Chrome and Safari, and searching terms were ‘‘FAS,’’ ‘‘FASD’’ and ‘‘Alaska.’’ Only English language articles were included.

Results Current policies in Alaska: Current prevention and treatment polices in Alaska fall under 5 broad categories: 1) training and education; 2) legislative and legal; 3) support services; 4) diagnostic and 5) epidemiology and surveillance. Training and education efforts have focused primarily on educating clinicians and other healthcare providers about FASD. Legal policy is a mixture of health advocacy and quality improvement to existing FASD services. These efforts include advocacy on behalf of the Alaska Native population by the Alaska Native Health Board. Various groups throughout the state provide support services for families and children. Effective diagnosis of FASD is provided by a variety of non-profit, governmental and community organizations throughout the state. Successful policies outside Alaska: Several policy approaches have driven successful prevention and treatment

strategies in the circumpolar region. These policy approaches include networking, coordination and appropriate utilization of technology. In Alberta, Canada, the FASD Service Network provides a system that has crossministry coordination of services for people with FASD. Canada FASD Research Network (CanFASD) provides educational and support services within schools, and public health outreach, mental health services and educational services for children with FASD and their families. A committee consisting of members from several different ministries within the government works to promote coordination of services (2). Canada currently uses telehealth to address health care access limitations specifically amongst the FASD population. When used locally, health care providers are able to offer a more comprehensive support system for children and increase participation in clinic sessions (3).

Discussion Considered policy recommendations: Based on the current policies, 5 policy recommendations were developed: 1) community-based identification, treatment and support of FAS/FASD; 2) early identification of FASD children to help secure intervention for children; 3) early identification of pregnant women at risk for alcohol abuse; 4) reduce barriers to treatment; and 5) systematic evaluation of needs and outcomes of individuals and families afflicted with FAS/FASD. The rural nature of most of Alaska and the unique culture of Alaska Native communities demands a community-based approach to break the cycle of alcohol abuse. This approach should focus on education, prevention and community support and should be the foundation for FASD interventions in Alaska. Focus on early intervention for FASD children is tied to long-term outcomes and is vital to these efforts, and all public or private service providers who may come in contact with FASD children should be trained to identify these children and to connect them with the interventional services available. It is important to have communitywide support to promote abstinence from alcohol during pregnancy. Healthcare providers should be trained to


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Prevalence per 10,000 Live Births

70 60

63.1

50 40 32.4

30 19.9 20 10

13.5 3.7

6.1

0 1996-1998

1997-1999

Alaska total

1998-2000

1999-2001

Alaska Native

2000-2002 Non-Native

Fig. 1. FAS prevalence by three-year moving averages, Alaska Birth Defects Registry, birth years 19961998 to 20002002.

recognize triggers for alcohol dependency and its strong correlation to mental health. Early intervention is critical for prevention of FASD as well, and local training should include risk factors such as maternal age and number of pregnancies. The difficulties caused by the extreme geographical barriers could be mitigated somewhat by the development of a mobile interdisciplinary team that would routinely travel through Alaska to provide diagnostic services and educational and interventional support to meet the local needs of women and children. Telemedicine should be implemented to further leverage the expertise of these specialized interdisciplinary teams. Finally, the development of surveys and research studies would improve understanding of the long-term needs of women and families suffering from alcohol dependency. Across the circumpolar region, major concerns for FAS treatment are coordination of care and funding constraints. The State of Alaska manages the majority of its FAS services through external organizations with almost 90% of the Governor’s 2012 FAS budget dedicated to grants. CanFASD has been identified as a potential model for Alaska. The Alaska Federal Health Care Access Network (AFHCAN), a program developed by the Alaska Native Tribal Health Consortium (ANTHC), is a proven cost-effective telehealth delivery program in Alaska but lacks an FAS component. Coordination of care is also constrained by the logistical challenges inherent to the state. Alaska is a vast territory of rough terrain and harsh living conditions. The state’s low population density means that great distances may separate patients, providers and needed services.

effective utilization of mobile applications technology and telemedicine. Successful implementation will require the involvement of stakeholders at the provider, policy and community level, and an on-going commitment to increasing access to high-speed and wireless Internet to rural communities. Within the context of budget constraints, all funds required to support this effort should be moved to the services side of the FAS budget from the current grants allocation. Furthermore, the state should dedicate 5% of the FAS grant budget towards the development of an online network, modelled after CanFASD, to coordinate interventions. Alaska should also require that all state grant recipients participate in this network. These recommendations would eliminate service redundancy to improve FAS programs while remaining budget neutral.

Conclusion

*Garrett Hartley Email: [email protected]

Therefore, it is recommended that future successful policy efforts focus on reducing barriers to treatment via

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References 1. Popova S, Stade B, Berkmuradov D, Lange S, Rehm J. What do we know about the economic impact of fetal alcohol spectrum disorder? A systematic literature review. Alcohol Alcohol. 2011;46(4):4907. 2. Milne D, Moorhouse T, Shikaze K, Cross-Ministry Members. A cross-ministry approach to FASD across the lifespan in Alberta. In: Riley E, Clarren S, Weinberg J, Jonsson E, editors. Fetal alcohol spectrum disorder: management and policy perspectives of FASD. 1st ed. Weinheim, Germany: Wiley; 2011. p. 35368. 3. Ens CDL, Hanlon-Dearman A, Longstaffe S, Millar MC. Using telehealth for assessment of fetal alcohol spectrum disorder: the experience of two Canadian rural and remote communities. Telemed J E Health. 2010;16:8727.



The healing constellation: a framework for understanding and treating trauma in Alaska Native women Wendy H. Arundale* Institute of Arctic Biology, University of Alaska Fairbanks, Fairbanks, AK, USA; Samaritan Counseling Center, Fairbanks, AK, USA; Psychiatry Section, Fairbanks Memorial Hospital, Fairbanks, AK, USA

Background Many Alaska Native women suffering with substance abuse, mental health issues or both have also experienced psychological trauma. Although the past 30 years has seen significant growth in our understanding of how trauma can affect many aspects of a woman’s life, treatment for Alaska Native women has sometimes been slow to reflect these developments. When treatment strategies focus on just a few elements of a woman’s distress, treatment may be unnecessarily prolonged or fail completely.

Objective Broad-based conceptual frameworks and treatment approaches are essential to avoiding these problems. Just as constellations guided early travellers, the Healing Constellation can provide such a conceptual framework and guide effective treatment. As a mnemonic device, it prompts us to recognize and examine the many factors that may contribute to a trauma survivor’s distress. Its complexity suggests a rich web of relationships among these factors and invites thoughtful exploration of treatment options. Complexity means there are a variety of entry points for treatment, places to start again if initial efforts fail, and insurance against narrowly focused, ‘‘magic bullet’’ approaches.

Design Figure 1 shows the Healing Constellation, shaped like a double-layered safety net, in simplified form. The following explanation can only hint at the complex relationships that the framework embodies (1). The constellation’s elements were chosen on the basis of theory and research in psychology, anthropology, substance abuse and medicine; the author’s clinical training and experience; and input from providers experienced in working with Alaska Native women and Alaska Native women themselves. Stars in the constellation correspond to the major knots or nodes in the net where intersecting strands come

together. The upper level nodes denote treatment modalities. The lower level nodes denote underpinning conceptual areas.

Results The first key star anchoring the net is Multicultural Competence and the Therapeutic Alliance. Alaska Native women’s treatment needs to be culturally appropriate and culturally competent. Its Basic Principles include being grounded in indigenous knowledge systems; being empowering, respectful and trauma sensitive; and having both overall programs and individual therapeutic alliances shaped by indigenous values (2). The second anchor star is the Concept of Trauma, beginning with concepts coming from Alaska Native culture [e.g. (3)]. Cultural and Historical Context is an extremely important conceptual star. Effective treatment requires knowing the specific culture and trauma history of the area, group and communities from which clients come from. A closely related conceptual star is Intergenerational Trauma. This concept and the ways it is understood by Native people provide major aspects of historical, cultural, social and psychological contexts crucial for understanding symptoms and providing successful treatment, that otherwise are likely to go unrecognized. Another closely related star is Attachment. Intergenerational trauma is transmitted by the ways members of one generation’s parent or otherwise relate to the next generation. Attachment concepts, which have crosscultural validity, provide a way to understand these extremely important relationships, and how they can either create or prevent intergenerational trauma. Substance Abuse, the next star, is often cited as a major factor in intergenerational trauma. The rates of cooccurrence are very high among Alaska Native women. Successful treatment requires specific knowledge about 1) women’s responses to substances; 2) women’s needs in effective treatment; 3) issues specific to Alaska Native women’s treatment; 4) treatment modalities that are


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Fig. 1. The Healing Constellation.

successful with Alaska Native women; and 5) traumasensitive treatment. The Interaction between Trauma and Substance Abuse star indicates that understanding these multiple linkages is essential to good treatment. Trauma and substance abuse are linked through families and communities, both central to Alaska Native life. A very common view of substance abuse by Alaska Native observers is as selfmedication for trauma symptoms. Thus, integrated therapy is more likely to be successful than the old model of substance abuse treatment first, then trauma therapy. Substance abuse may serve many other functions for trauma survivors. The Neuropsychology of Trauma star is increasingly important as our understanding of its role in attachment, substance abuse, intergenerational trauma and health effects grows. Neuropsychology informs us about trauma’s very real disrupting, dysregulating effects on the brain and body, for example, on the developing brains of children, hampering information processing and memory. It also helps us to understand how healthy attachment and various therapies can help prevent or mitigate trauma’s effects. The final conceptual star recognizes that trauma and substance abuse can increase the risks for a host

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of medical conditions. Treating these conditions is an important part of treating trauma. Such treatment may be a prerequisite to diagnosing mental health issues accurately. A key star on the treatment level is Assessment. Along with the Basic Principles cited earlier, assessment needs to embody a ‘‘whole person’’ approach and to view symptoms as adaptations to what took place. Recognizing growth and strengths and the often-victimizing contexts of Euroamerican culture, that can introduce negative biases at several assessment levels, are also key. Assessments for substance abuse, TBI, sensory integration problems and other disabilities including FASD, and medical problems are important elements. Stars for medical treatment and psychopharmacology are somewhat self-explanatory, but require application of the Basic Principles. Ethnopharmacological considerations are important for both. The Western and Alternative Therapies star denotes: (1) valuable treatment ideas such as the therapeutic window and the three stage treatment model; (2) various western therapies, such as cognitive behavioral therapy, group therapy for trauma, narrative therapy, dialectical behavioral therapy, EMDR and sensorimotor therapy; and (3) alternative therapies, such as therapeutic yoga,


Behavioral Health

therapeutic massage, acupressure, acupuncture, and guided imagery, which offer promise if guided by the Basic Principles. The final, very important star is Culturally Specific Healing Practices. Some of these include: spending time with healthy elders sharing stories, teachings and wisdom; traditional songs and dances; drumming; prayer; native craft activities; sweat baths; treatment by tribal doctors and native healers; talking circles; subsistence activities; spending time reconnecting with one’s land; learning the history of one’s home area and having its trauma history acknowledged; and learning and telling the stories of one’s own culture and community.

Conclusions The Healing Constellation has important implications for treatment, research and policy development.

References 1. Arundale WH. The Healing Constellation: a conceptual framework for treating trauma among Athabaskan women in Alaska [dissertation]. Cincinnati, OH: The Union Institute and University; 2006. p. 464. 2. Segal B, Burgess D, DeGross D, Frank P, Hild C, Saylor B. Alaska Natives combating substance and related violence through self-healing: a report for the people. Anchorage, AK: The Center for Alcohol and Addiction Studies, The Institute for Circumpolar Health Studies, University of Alaska Anchorage; 1999. p. 116. 3. Napoleon H. Yuuyaraq: the way of the human being. Fairbanks, AK: Alaska Native Knowledge Network, University of Alaska Fairbanks; 1996. p. 65. *Wendy H. Arundale Email: [email protected]


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Preventing interpersonal violence for adults with developmental disabilities in Alaska Karen Ward* and Julie Atkinson Center for Human Development, University of Alaska Anchorage, Anchorage, AK, USA

Introduction Meaningful relationships are important in the lives of all people, including adults with developmental disabilities. In a recent study exploring the relationships of adults with developmental disabilities, 85% of the respondents report that they were in or had been in a romantic relationship since graduating high school (1). Of those who had been or were in relationships, 60% had experienced interpersonal violence (1). It is well documented that persons with disabilities are victims of interpersonal violence at higher rates than peers without disabilities (2). The study concluded that adults with developmental disabilities need more opportunities to develop healthy, meaningful relationships.

Background There is a paucity of empirical research documenting the effectiveness of approaches for teaching abuse protection skills to persons with developmental disabilities, and no known studies that examine teaching the skills for healthy relationships, or combining these skills with abuse protection. The Friendships & Dating Program (FDP) was developed by a multidisciplinary team at the University of Alaska Anchorage Center for Human Development (CHD), as a primary prevention program. The goals of the program are to prevent violence in relationships and to teach social skills necessary to develop healthy, meaningful relationships for adults with intellectual and developmental disabilities. The content of the FDP included salient concepts and skills delivered and practiced by participants in a sequential order: feelings, types of relationships, personal boundaries, communication, meeting people and first impressions, planning social activities, the dating process, personal safety, sexual health and gender differences. The FDP teaches skills in class sessions combining several multi-modal approaches including: discussions, role rehearsals, games, worksheets, hand-outs, videos, DVDs, slides, posters, drawings, guest speakers and modelling. Experiential activities in community settings such as

246

malls, coffee shops and parks are conducted to reinforce and practice skills taught in class sessions. A Friendships & Dating Manual provided all materials for facilitators to easily conduct sessions. Specific protocol for each session including learning and behavioral objectives, materials needed, session activities, scripts for teaching each concept and skill, and community activities. Suggested time sequences were provided for each activity to help facilitators accomplish the session objectives. The FDP is a 20-session program taught 2 times per week over a 10-week period in co-ed groups of 68 participants. The FDP incorporates innovative approaches that combine: 1) preventing and/or decreasing interpersonal violence; 2) increasing social networks; and 3) increasing social activities.

Methods CHD recruits Alaskan agencies that serve adults with intellectual and developmental disabilities to participate in the FDP. Personnel from these community agencies with at least 1 year experience and interest in the topic are trained as facilitators. Facilitators attend a 2-day training session to learn how to implement the program. Once trained, they return to their home community and recruit participants to take part in the program. Program participants must 1) be over 18 years old, 2) experience an intellectual and/or developmental disability, and 3) not have a history of inappropriate sexual or violent behaviors. To date, CHD has trained 48 facilitators from 13 agencies across the state to deliver the FDP. The program has been piloted with 126 adults with developmental disabilities in Alaska. Fidelity data were collected from facilitators on a weekly basis regarding the number of participants present at each session, what session topics were covered and if any modifications to the program were made. Qualitative data were collected through focus group interviews with participants and with care providers. Quantitative outcome data were collected at baseline, post intervention and 10 weeks after the program ended. Outcome data examined social networks of the participants and the


Behavioral Health

number of incidents of interpersonal violence. Institutional review board approval and participant consent were received prior to data collection activities.

Results Data regarding treatment fidelity were examined using a process evaluation model (3). Results showed that facilitators were able to deliver the FDP as intended and followed the FDP manual (3). Fidelity data also confirmed participants of the program engaged at high levels over the 10-week period (3). Qualitative feedback from participants reports FDP strategies resulted in improved social relationships. One participant shared, ‘‘I am in a relationship right now and it’s going okay, but it’s kind of rocky and I think that I can use what I have learned to make it better.’’ Feedback from care providers of participants emphasized the need for the FDP and the opportunity to develop healthy social skills. One care provider stated, ‘‘I think my client learned how to turn a boy down in a positive way. I think she was comfortable letting someone know that hey, she is not ready to date. Because before she used to get frustrated . . . and she wouldn’t tell someone that she didn’t want a boyfriend, and then after the class she dealt with it in a different way.’’ Quantitative data were gathered relating to the number of incidents of interpersonal violence and participants social networks. The data were analyzed utilizing a piecewise linear mixed model approach. The results showed an average of 2.3 incidents of interpersonal violence at baseline, which was significantly decreased by a mean of 1.4 (p 0.024) at the end of the intervention. Further, the data showed an average social network size of 4.8 at baseline, which was significantly increased

by a mean of 2.5 (p 0.005) at the end of the intervention. The data also showed the types of social activities that participants engaged in (i.e. going out to eat, dancing, bike rides, etc.) more than doubled by the end of the intervention.

Conclusion The FDP is based on the principle that safety training alone is not enough to prevent interpersonal violence. Adults with intellectual and developmental disabilities also need opportunities to acquire and practice skills necessary to engage in meaningful relationships. Although population sample size is small, the combination of these skill areas seems to be an effective strategy to prevent and/or decrease the number of incidents of interpersonal violence and to promote healthy social relationships. Additional research should be conducted on the development of meaningful relationships for people with developmental disabilities and the prevention of interpersonal violence.

References 1. Ward KM, Bosek RL, Trimble E. Romantic relationships and interpersonal violence among adults with developmental disabilities. Intell Dev Disabil. 2010;48:8998. 2. Rand MR, Harrell E. Crime against people with disabilities, 2007. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics; 2009. Report No.: NCJ 227814. 3. Ward KM, Windsor R, Atkinson JP. A process evaluation of the Friendships and Dating Program for adults with developmental disabilities: measuring the fidelity of program delivery. Res Dev Disabil. 2012;33:6975. *Karen Ward Email: [email protected]


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The effect of iqmik on oxidative stress in human gingival epithelial cells Gaelen K. Dwyer1,2 and Cindy Knall1* 1

WWAMI School of Medical Education, University of Alaska, Anchorage, AK, USA; 2Graduate Interdisciplinary Studies, University of Alaska, Fairbanks, AK, USA

se of smokeless tobacco (SLT) has been identified as a risk factor for head and neck squamous cell carcinoma (1). The percentage of Alaska Native peoples who use SLT is more than 5 times that of non-Alaska Natives. The high rate of SLT use among Alaska Native peoples most likely contributes to the significantly higher rates of head and neck cancer seen in this population. The use of SLT is concentrated in Southwest Alaska where more than 20% of all adult Alaska Native peoples use SLT with nearly 50% of this population using iqmik (2). Iqmik is a combination of tobacco leaves mixed with the ash of Phellinus igniarius (punk fungus). The fungus is burned to ash then mixed with the tobacco by mastication. Many women will use iqmik, and will even switch from cigarettes and commercial forms of SLT to iqmik while they are pregnant, because they believe it is safer (3). However, use of SLT has been identified as a risk factor for head and neck squamous cell carcinoma (1). Tobacco contains a large number of chemicals, including carcinogenic metals, which cause inflammation, oxidative stress, and apoptosis in cells. The ash component of iqmik contains even higher levels of carcinogenic metals such as cadmium, cobalt, and nickel than tobacco, as well as higher concentrations of alkali metals and alkaline earth metals, which contribute to the overall alkaline pH of iqmik (3). One mechanism for the carcinogenic effects of metals is metal-toxicity-induced oxidative stress (4). Reactive oxygen species (ROS), part of the oxidative stress, damages DNA through base modification, which if uncorrected can lead to mutagenesis and tumour formation. The goal of this experiment is to test the hypothesis that iqmik would produce a greater oxidative stress than either air-cured tobacco or punk ash alone. To determine the level of oxidative stress triggered by iqmik and its components, we developed an in vitro exposure system to investigate oxidative stress in human gingival epithelial cells.

U

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Methods Cell culture Primary human gingival epithelial progenitor cells (HGEPs) (CELLnTEC Advanced Cell Systems AG, Bern, Switzerland) were grown in 96-well plates for 68 days in CnT-24 PCT Oral Epithelium Medium (CELLnTEC). One day prior to confluency, the medium was changed to CnT-32 Oral Epithelium Medium (CELLnTEC), cultures were grown for 24 h and induced to differentiate using 1 mM CaCl2 as per manufacturer’s instructions. HGEPs were differentiated for 96 h prior to use. Extract preparation Iqmik was prepared without mastication by combining 0.5 g punk ash and 0.5 g chopped air-cured tobacco in a vessel. Each sample, air-cured tobacco, punk ash or iqmik, (1 g total weight) was extracted daily in 30 mL freshly prepared artificial human saliva (5) resulting in a 33.3 mg/mL (w/v) extract. Each sample was inverted seven times and incubated for 30 min at 378C and 5% CO2. Samples were centrifuged for 5 min at 2,000 g, and the supernatant was filter sterilized through a 0.2-mm filter. Exposure and ROS detection Total ROS was measured with membrane-permeable oxidation-sensitive fluorescent dye dichlorofluorescein diacetate (H2DCFDA) (Invitrogen, Grand Island, NY, USA). Prior to exposure with extracts, differentiated cells were washed with phosphate buffer saline (PBS) and incubated for 1 h with H2DCFDA (15 mM), or PBS alone as a control. Following a PBS wash, cells were incubated with 1 mM CaCl2 CnT-32 media for 30 min and washed again. Prepared cells were exposed for 3 h to artificial saliva or artificial saliva extracts. Each condition was tested in triplicate. Fluorescence measurements were obtained using a fluorescent microplate reader (Molecular Devices, Sunnyvale, CA, USA) (6). Statistical significance was determined using Student’s t-test.


Behavioral Health

Results As shown in Fig. 1, iqmik extracts produced significantly more ROS compared to air-cured tobacco extracts (p 50.0002), punk ash extracts (p 50.00004) or artificial saliva alone (p50.00001). The fold changes between iqmik and these other conditions were 2.8-, 4.3- and 5.3folds, respectively. Interestingly, punk ash extract produced only slightly more ROS than artificial saliva alone and the difference was not statistically significant (Fig. 1). Although, air-cured tobacco extract produced significantly more ROS than artificial saliva (p50.01), the difference between air-cured tobacco extract and punk ash extract did not meet significance (p50.08). Therefore, the dramatic increase in ROS produced in differentiated HGEPs exposed to iqmik demonstrates a synergistic effect between air-cured tobacco and punk ash in creating oxidative stress within exposed cells.

Conclusion Treatments of HGEPs with artificial saliva extracts of iqmik resulted in dramatically more ROS generation than any other condition. The combination of punk ash with air-cured tobacco significantly affects the way the cell responds to components in the air-cured tobacco and punk ash. This is even more compelling since the iqmik extract had only half the total punk ash and air-cured tobacco that elicited the ROS response. The fact that this increase was more than additive compared to the 2 individual components, air-cured tobacco and punk ash, suggests a synergistic effect between chemicals within the air-cured tobacco and punk ash. ROS species damage lipids, proteins, and DNA and activate redox-sensitive transcription factors that are active in cell growth, 200 180 160 140 RFU

120 100 80 60 40 20 0

Saliva

Ash

Tobacco

inflammation, and apoptosis. Oxidative stress initiates mutagenesis and disrupts normal cell growth checkpoints, leading to tumour development (4). This suggests that exposure to iqmik most likely creates a more harmful intracellular environment which could contribute to greater inflammation, carcinogenic risk and higher rates of head and neck cancers among Alaska Native peoples.

Conflict of interest and funding None of the study authors have any relationships, financial or otherwise, which could potentially influence the results or interpretation of the work being submitted for consideration. Research reported in this publication was supported by the National Institute of General Medical Sciences of the National Institutes of Health under Award Number P20GM103395 as an Affiliate Faculty Research Grant to C.K. and an Alaska INBRE Undergraduate Student Project Support (USPS) Award to G.D. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. This work was also supported by the UAA Office of Undergraduate Research and Scholarship to G.D., a UAA Faculty Development Grant and an Innovate Award to C.K.

References 1. IARC. Smokeless Tobacco and Some Tobacco-specific NNitrosamines. In: International Agency for Research on Cancer, editor. IARC Monographs on the evaluation of carcinogenic risks in humans. 89. Lyon, FR: World Health Organization; 2007. p. 626. 2. DPH. Alaska Tobacco Facts. In: Health DoP, editor. 2012 Update ed. Juneau: Department of Health and Social Services; 2012. 3. Blanchette RA, Renner CC, Held BW, Enouch C, Angstman S. The current uses of Phellinus igniarius by the Eskimos of western Alaska. Mycologist. 2002;16:1425. 4. Beyersmann D, Hartwig A. Carcinogenic metal compounds: recent insight into molecular and cellular mechanisms. Arch Toxicol. 2008;82(8):493512. 5. Sfondrini MF, Cacciafesta V, Maffia E, Massironi S, Scribante A, Alberti G, et al. Chromium release from new stainless steel, recycled and nickel-free orthodontic brackets. Angle Orthod. 2009;79(2):3617. 6. Mitchell C, Joyce AR, Piper JT, McKallip RJ, Fariss MW. Role of oxidative stress and MAPK signaling in reference moist smokeless tobacco-induced HOK-16B cell death. Toxicol Lett. 201019;195(1):2330.

Iqmik

Fig. 1. Intracellular ROS in HGEPs exposed to extracts of Iqmik and its components. HGEPs were exposed for 3 h to artificial saliva extracts of punk ash, air-cured tobacco or iqmik or artificial saliva alone. ROS was measured in relative fluorescence units (RFU), as described in ‘‘Methods’’ section. Data shown represent the mean9 standard deviation of triplicate samples.

*Cindy Knall Email: [email protected]


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Community-driven alcohol policy and foetal alcohol spectrum disorder prevention: implications for Canada’s North? Nancy Poole1,2*, Tasnim Nathoo1 and Arlene Hache´2,3 1

British Columbia Centre of Excellence for Women’s Health, Vancouver, BC, Canada; 2Canada FASD Research Network, Vancouver, BC, Canada; 3Centre for Northern Families, Yellowknife, NT, Canada

Introduction This article discusses the potentially important role of alcohol policy in northern communities, in affecting alcohol use in pregnancy and the significant risk of foetal alcohol spectrum disorder (FASD).

Background FASD is a term used to describe the range of harms that can result from prenatal alcohol exposure. Affecting approximately 1% of the population, it is considered a leading known cause of developmental disability in Canada. While comprehensive data on rates of FASD and alcohol use during pregnancy in northern communities are lacking, limited evidence suggests that rates in many communities are above the national average, and many communities report on-going concerns with high rates of alcohol and other substance misuse. Prevention activities to address FASD began in the late 1970s and 1980s. These early efforts tended to be childcentred and focused on warning women of the dangers of alcohol consumption during pregnancy. This simplistic approach has proved to be of limited value as general alcohol use and FASD rates are intertwined with broader determinants of women’s and children’s health, including overall health, nutrition, experiences of violence and trauma, and access to sexual and reproductive health services and prenatal care. In general, alcohol policy is often a neglected area for FASD prevention efforts. In particular, community-driven alcohol policy may be an effective FASD prevention strategy for northern communities. In Canada, in the 1970s, provisions were introduced in provincial and territorial Liquor Control Acts that allowed communities to decide, through plebiscite, their own approach to alcohol control. Yet, the use of these provisions as an approach to FASD prevention has been little discussed in the Canadian context. We examine the use of communitydriven alcohol policy in 2 other jurisdictions, northern

250

Alaska and remote Western Australia, to explore the possible role of alcohol policy in FASD prevention efforts in northern Canada.

Methods The authors identify the prevalence of alcohol policies currently in place in northern Canadian communities with the goal of illustrating the potential for this policy to serve as a mechanism for FASD prevention. Two case examples from jurisdictions beyond Canada are employed to illustrate approaches to alcohol policy in northern and remote communities, where affecting prenatal alcohol rates was an explicit goal.

Results Prevalence of alcohol policy in Canada’s North A survey of 78 primarily First Nations, Me´tis and Inuit communities in the Yukon, Northwest Territories and Nunavut in 2008 found that half (39) of the communities had some form of alcohol restriction. Communities with regulations tended to have smaller and younger populations, a greater percentage of people with First Nations, Me´tis or Inuit origin and were more geographically isolated than those with no regulation (1). Policies included approaches, such as making communities completely dry (where alcohol is entirely prohibited); restricting the quantity of alcohol allowed for individual possession; limiting liquor store hours; or regulating the sale and use of alcohol in public places or gatherings. Case example 1 barrow, Alaska In 1994, Barrow, through a local referendum, became the largest community in Alaska to have a total ban on alcohol (i.e. the sale and possession of alcohol was prohibited). During the first year, the community reported a drop in felony assaults by 86%, fights by 61% and drunk driving by 79%. While other communities have reported changes in a range of indicators after similar


Behavioral Health

policy shifts, Barrow is one of the few communities that tracked changes in prenatal alcohol exposure. During the initial period of the ban (November 1994March 1995), self-reported alcohol and other substance use in women (n73) was compared with that of a similar group of women (n 275) prior to the ban (January 1992April 1994). Both groups received the same standard prenatal care with FASD education. During this 5-month period, alcohol use during pregnancy dropped significantly, from 42 to 9% (2). The total ban was not without controversy and a year later the community voted again and shifted from being a ‘‘dry’’ community to a ‘‘damp’’ community. However, it is clear, that in terms of prenatal alcohol consumption, the effect of the ban was substantial. This community is comparable geographically to northern Canadian communities, and the ‘‘dry’’ policy approach is common to alcohol policy in some northern Canadian communities. It clearly illustrates the potential for alcohol bans to affect rates of drinking in pregnancy/ incidence of FASD.

Case example 2 fitzroy valley, Western Australia Another case of the connections between communitydriven alcohol policy and FASD prevention is seen in more recent events in remote Fitzroy Valley in the Kimberley region of Western Australia. In 2007, concerns about the harms of alcohol in the community came to a peak. In that year, there were 55 deaths (13 being suicides), and alcohol was a factor in many of the deaths. Aboriginal women in the community took action and successfully lobbied the Western Australia liquor licencing board for restrictions on the sale of full-strength take-away alcohol. This story is told in the film Yajilarra, produced by Jane Latimer and directed by Melanie Hogan. These alcohol restrictions had both immediate and long-lasting effects. One year after the restrictions were introduced, an independent evaluation showed a 28% reduction in alcohol-related police tasks, a 36% reduction in alcohol-related presentations to hospital, a 14% increase in school attendance and a reduction in the sale of pure alcohol from the Crossing Inn from 104 l/day to 23 l/day (3). Concerns about high rates of alcohol use during pregnancy continued in the wake of the restrictions and,

in 2009, the community developed a strategy for the diagnosis and prevention of FASD and supporting parents and caregivers of children with FASD. While this community is located in the southern hemisphere, it is a remote Aboriginal community similar to many northern Canadian communities. Their harmreducing approach to alcohol policy has similarities to alcohol policy in some northern Canadian communities. To this day, this small community of indigenous Australians is using their harm-reducing alcohol policy, paired with awareness-raising and support strategies, to affect the rate of drinking in pregnancy/incidence of FASD. As such, they are a model for a comprehensive community approach, one which has received accolades from the United Nations.

Conclusion Clearly, communities in Canada’s north are taking an active role in addressing the harms of alcohol use through the policy process. However, it does not appear at this time that FASD prevention is part of these discussions nor is it clear to what extent women are engaged in this policymaking process. Yet, regardless of the actual impact of these policies on FASD rates, community-driven alcohol policy does appear to offer individuals an opportunity to become active participants in FASD prevention efforts. Evidence from other jurisdictions suggests that community-driven alcohol policy, especially with its potential for Aboriginal and women involvement in leadership, may be a particularly effective FASD prevention approach for northern Canada.

References 1. Davison C, Ford CS, Peters PA, Hawe P. Community-driven alcohol policy in Canada’s northern territories 19702008. Health Policy. 2011;102:3440. 2. Bowerman RJ. The effect of a community-supported alcohol ban on prenatal alcohol and other substance abuse. Am J Public Health. 1997;87:13789. 3. Elliott E, Latimer J, Fitzpatrick J, Oscar J, Carter M. There’s hope in the valley. J Paediatr Child Health. 2012;48:1902. *Nancy Poole Email: [email protected]


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Academic performance and alcohol use among college students from urban and rural areas in Alaska Rebekah Burket* and Monica C. Skewes Center for Alaska Native Health Research and Department of Psychology, University of Alaska Fairbanks, Fairbanks, AK, USA

outh in Alaska’s circumpolar north often migrate from rural areas in Alaska to urban centers to pursue post-secondary education. Retention rates of rural students lag behind their urban counterparts despite support services that aim to facilitate rural students’ adjustment to college life in an urban environment. Stressors related to behavioral health and drinking style may contribute to the high rates of attrition in this population. This research examined the associations between rurality, alcohol use, and academic performance among students at a circumpolar university. Potential intervention strategies are proposed. Rural status was operationalised using Cromartie and Bucholtz’s (2008) population-based cut-off of 2,500 people or less for non-Alaskan locales (1). Rural status for Alaskans was established using the State of Alaska’s definition of rural communities as those with populations of 5,000 or less that are not connected to Anchorage or Fairbanks by road or rail and those with populations of 2,000 or less that are connected to those cities. In this study, rurality refers only to geographic status and does not indicate ethnicity.

Y

Method

Measures Academic performance was assessed with self-reported grade point average (GPA) and the number of classes skipped in an average semester. Alcohol problems were assessed using the Young Adult Alcohol Consequences Questionnaire (YAACQ) and the Short Alcohol Dependence Data questionnaire (SADD). The YAACQ is a 48-item measure of alcohol-related consequences in young adults (2). Scores range from 0 to 48 with higher scores indicating greater alcohol problems. The SADD is a 15-item measure of alcohol dependence (3). Scores range from 0 to 45 with higher scores indicating greater frequency of alcohol dependence symptoms.

Results

Procedure A sample of 298 undergraduate students volunteered to participate in the research by responding to advertisements for extra credit in college classes in exchange for participating in the research. Students completed a self-report paper and pencil questionnaire that assessed rurality, academic performance, alcohol use and other behavioral health variables. The university Institutional Review Board approved all methods prior to data collection. Analysis Each respondent was given a code to indicate the person’s status as rural or urban and resident of Alaska or nonresident. A subsample of 277 students was used in the

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analyses because 21 students (7%) did not provide sufficient information to be classified and were excluded from subsequent analyses. Analysis of variance was used to compare responses between students from rural areas of Alaska, urban Alaska and non-residents in order to evaluate associations between rural status and academic performance, alcohol consumption and overall behavioral health.

Participants were undergraduate students, mostly freshmen (41.9%, n125). The remainder of students was an equal distribution of sophomores, juniors and seniors. The respondents’ ages ranged from 18 to 52 years (M23.03, SD6.53). Ninety percent of the sample was between 18 and 31 years of age. The sample was predominantly female (63.4%, n189). Most respondents reported their ethnicity as White (67.1%, n 200) or Alaska Native/American Indian (16.4%, n 49), but other ethnic minorities were also represented. The majority of participants were from Alaska (64.1%, n 191). Students from rural areas of Alaska made up 17.8% of the sample (n53), urban students from Alaska accounted for 46.3% (n 138) and 28.9% of respondents were from outside Alaska (n 86).


Behavioral Health

Urban students reported significantly higher GPAs than rural students, F(1,275)31.30, p B0.001, h2 0.10, and missed significantly fewer days of class than rural students, F(1,276) 8.29, p B0.01, h2 0.03, regardless of ethnicity. The analyses found no significant difference between rural and urban students with regard to the age of first alcoholic drink or classes missed due to alcohol consequences. However, students from rural areas in Alaska scored significantly higher on the SADD, F(1,262)7.27, p B0.01, h2 0.03, and on the YAACQ, F(1,256)4.36, p B0.05, h2 0.02. Alpha was set at 0.05 for all analyses.

Conclusions Students from rural locations did not report initiating drinking at an earlier age than their urban counterparts. Rural students did not claim to miss any more class due to alcohol consequences than their urban peers although urban students missed fewer days of class and had higher GPAs. Students from rural areas of Alaska did endorse greater alcohol-related consequences and alcohol dependence when they use alcohol. The generalisability of the findings is limited by the self-selected sample that is non-representative of the general university population. Further research to identify drinking style and beverage preference among people from rural areas of Alaska is needed to articulate the mechanisms for increased alcohol consequences and implications for school success. Harm reduction approaches such as the Brief Alcohol Screening and Intervention for College Students

(BASICS) may benefit this population. The BASICS provides a two-session intervention to give students accurate information about how much their peers are using alcohol. Information on how to consume alcohol responsibly is included such as how to moderate alcohol consumption with meals and non-alcoholic beverages. Raising awareness of the hazards of binge-style drinking may be an especially relevant harm reduction intervention for students from rural areas who encounter stressors related to the rural-to-urban transition in addition to adjusting to college life.

Acknowledgements We thank the students who participated in this research.

References 1. Cromartie J, Bucholtz S. Defining the ‘‘rural’’ in rural America. Amber Waves. 2008;6:2834. 2. Read JP, Kahler CW, Strong DR, Colder CR. Development and preliminary validation of the young adult alcohol consequences questionnaire. J Stud Alcohol. 2006;67:16977. 3. Davidson R, Raistrick D. The validity of the short alcohol dependence data (SADD) questionnaire: a short self-report questionnaire for the assessment of alcohol dependence. Br J Addict. 1986;81:21722. *Rebekah Burket Email: [email protected]


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Epidemiological portrait of behavior problems within an Inuit sample of school-aged Nunavik children: preliminary report Gabrielle Be´gin1,2, Sandra W. Jacobson3, Nadine Forget-Dubois1,2, Jocelyne Gagnon1, E´ric Dewailly1,2, Pierre Ayotte1,2, Joseph L. Jacobson3 and Gina Muckle1,2* 1

Universite´ Laval, Quebec, QC, Canada; 2Centre de recherche du Centre Hospitalier Universitaire de Que´bec (CHUQ), Quebec, QC, Canada; 3Departement of Psychiatry and Behavioural Neurosciences, The Wayne State University School of Medicine, Detroit, MI, USA

he Inuit of Nunavik experience a variety of psycho-social problems that tend to compromise optimal child development. Among these problems are teenage pregnancy, domestic violence, alcohol abuse, as well as a suicide rate that is among the highest in the world (1). Both internalising behavioral problems (IBP) and externalising behavioral problems (EBP) can appear very early in development and can lead to sustained trajectories of delinquency, criminality, rejection by peers, depression and anxiety (2). IBP include symptoms of anxiety, depression and social withdrawal or rejection, whereas EBP take the form of impulsive, delinquent or aggressive behaviors.

T

Objective This research project seeks to document the presence of behavior problems (BP) among school-aged Inuit in Nunavik and to examine their link with psycho-social risk factors to which the children are exposed.

Methods Participants The participants were 284 Inuit children between 8 and 14 years of age (M 11.3 years; SD 0.8 year) living in Nunavik. The participants were drawn from 2 earlier cohorts: the Cord Blood Monitoring Program and the Child Health and Development Study (3,4) for further information about the recruitment process. The study was conducted between 2005 and 2010. Prenatal exposure to mercury and polychlorinated biphenyls was documented in the blood of the umbilical cord, and children exposed to

254

the highest level of mercury were prioritised for the schoolage follow-up.

Instruments Behavior Two instruments completed by the child’s teacher were used: the Disruptive Behaviour Disorders Rating Scale (DBD) and the Teacher’s Report Form (TRF). Psycho-social and biological variables The mother’s age, level of education, employment status and occupation, the welfare status, parity before birth of the target child, breastfeeding status, the number of children living with the mother, the number of people per room in the home, language spoken during the interview, the child’s adoption status, maternal psychological distress, domestic violence, and the mother’s nonverbal reasoning ability (Raven) and verbal intelligence peabody picture vocabulary test (PPVT) (the latter used as an index of mother’s acculturation) were all assessed. The biological determinants recorded were prenatal and contemporary exposure to environmental contaminants (polychlorinated biphenyls, lead and methylmercury), as well as exposure to tobacco, alcohol and illicit drugs, as measured during the maternal interview at 1 and 11 years. We also obtained the levels of omega-3 polyunsaturated fatty acids (n-3 PUFAs). Protocol The parents of selected children were contacted by telephone. A maternal interview lasting approximately 2 hours was carried out by a research assistant. The team nurse obtained a blood sample from the child. The child’s


Behavioral Health

teacher completed the TRF and the DBD. The ethics committees of Universite´ Laval and Wayne State University approved this study.

Statistical analysis The distributions were inspected visually for normality. Internal consistency of sub-scales of the TRF was documented using Cronbach’s-a test (0.7750.948). The cut-off point chosen for the identification of the risk groups was the 75th percentile of the distribution of the TRF scales, where scores ]75th percentile correspond to 1 (presence of difficulties) and scores B75th percentile correspond to 0 (absence of difficulties). We used latent class analysis (LCA) to expose different patterns of behavior problems among the participants, after which we performed Chi-square and ANOVAs.

Results Different LCA models with 25 classes were tested and compared using fit statistics of the Bayes Information Criteria (BIC), the Consistent Akaike Information Criteria (CAIC) and the Average Weight of Evidence (AWE). The best fit was found for a 3-class model, according to the criteria of the BIC and the CAIC. Among the 284 children assessed, 63% were in the notat-risk class (a), 20% were in the class at risk of internalising problems (b) and 17% were in the class at risk of externalising problems (c). Two Chi-square tests showed that belonging to a class was associated with the sex of the child [x2 (2, N 284) 9.154, p 0.010], as well as with breastfeeding status [x2 (2, N 277) 7.392, p 0.025]. Boys were more at risk than girls of belonging to the class at risk of EBP, while girls were underrepresented in the not-at-risk class but over-represented in the class at risk for IBP. Children in the low-risk class were more likely to have been breastfed, while the opposite tendency was observed in the 2 other classes. ANOVA results indicated that the mean scores for the mother’s educational level [F (2.1) 3.058, p 0.049], and on Raven’s [F (2,1) 3.888, p0.022], varied depending on which one of the 3 classes the subject belonged to. Mothers of children in the IBP class had a higher average education level than the mothers of children in the EBP class, while for the Raven (non-verbal intelligence test used as an index of acculturation in this population), mothers of children in the low risk class had a higher average score than the mothers in the EBP class.

Conclusions Three classes of risk emerged from the latent class analyses. Boys were more at risk of EBP while girls were more at risk of IBP. Breastfeeding may be a protective factor against the development of BP, since more breastfed children were found in the low-risk class whereas the contrary was observed for the 2 at-risk classes. Low maternal educational level and lower non-verbal intelligence were associated with children belonging to the class at risk of developing externalising BP, a finding in agreement with the literature on the subject (5).

Strengths and limitations The Inuit population is seldom studied for the presence of BP and their associated risk factors. Despite a transversal research design, certain longitudinal elements rarely taken into account are found here, such as pre- and postnatal biological factors, aspects related to pregnancy and breastfeeding, and consumption of substances by the mother. The research instruments were not validated for this population. Further research is needed to clarify the impact of pre- and post-natal factors on the development of BP in this population.

References 1. Commission des droits de la personne et des droits de la jeunesse [Humanrights and youth protection commission]. Nunavik: report, conclusions of the investigation and recommendations. Investigation intochild and youth protection services in Ungava Bay and Hudson Bay Que´bec, QC, Canada. 2007; 87 p. 2. Keiley MK, Lofthouse N, Bates JE, Dodge KA, Pettit GS. Differential risks of covarying and pure components in mother and teacher reports of externalizing and internalizing behavior across ages 5 to 14. J Abnorm Child Psych. 2003;31:26783. 3. Jacobson JL, Jacobson SW, Muckle G, Kaplan-Estrin M, Ayotte P, Dewailly E. Beneficial effects of a polyunsaturatedfatty acid on infant development: evidence from the Inuit of Arctic Quebec. J Pediatr. 2008;152:35662. 4. Muckle G, Ayotte P, Dewailly E, Jacobson SW, Jacobson JL. Prenatal exposure of the northern Quebec inuit infants to environmental contaminants. Environ Health Perspect. 2001; 109:12919. 5. Kwon JY. The relationship between parenting stress, parental intelligence and child behavior problems in a study of Korean preschool mothers. Early Child Dev Care. 2007;177:44960. *Gina Muckle Email: [email protected]


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Maternal screening for domestic violence at paediatric visits: physicians’ practices and perspectives Linda Chamberlain* University of Alaska at Anchorage, Anchorage, AK, USA; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

hysicians are in a unique position to assess for domestic violence (DV) at paediatric visits and assist families that are living with violence (1). Children exposed to DV are at increased risk of child maltreatment and are more likely to experience physical, behavioral, psychological and social disorders during childhood and later in life (1,2). While research indicates that as many as 40% of mothers seen at paediatric visits will disclose DV when asked, there is very little information regarding whether physicians are aware of screening recommendations, the impact of violence on children or strategies for screening at paediatric visits (3). The primary objectives of our study were to (a) examine physicians’ maternal screening practices for DV at different types of paediatric visits; (b) assess physicians’ opinions about barriers to screening for DV during paediatric visits; and (c) identify predictors of screening mothers for DV.

P

prevalence of children exposed to DV among families seen in their practices. An introductory letter about the study was sent to all study participants prior to mailing out the questionnaire. The questionnaire was mailed out 3 times; a reminder postcard was sent out approximately 2 weeks after the first mailing of the questionnaire. Data analyses were done with SPSS software. Forward stepwise logistic regression models were constructed to select predictor variables associated with physicians’ likelihood of screening for DV at different types of paediatric visits. Perceived barriers were dichotomised as not a barrier versus a barrier (minor or major). Physicians’ screening practices were coded as never versus sometimes/ often/always. Physicians’ perceptions about maternal screening for DV that were measured by level of agreement were dichotomised (disagree/neutral versus agree/ strongly agree). Statistical significance was defined as p B0.05 for all statistical comparisons.

Methods

Results

A cross-sectional questionnaire about current screening practices for DV was mailed to all physicians licensed in family practice, general practice, paediatrics, internal medicine, emergency medicine, psychiatry and family therapy in Alaska. The questionnaire design was informed by publications on barriers to screening, pilot-testing with paediatricians and recommendations from experts in the field. The 4-page questionnaire, in booklet format, consisted of 17 questions that took approximately 10 minutes to answer. A definition of DV and examples of screening questions were provided on the front of the questionnaire. In addition to questions on physicians’ demographics, respondents were asked about the types of DV training they had in the past 3 years. Frequency of screening for DV at different types of paediatric visits was assessed using a 4-point Likert Scale (never, sometimes, often or always). Respondents were asked to rate perceived barriers to screening mothers for DV at paediatric visits, indicate their level of agreement with statements about screening for DV in the paediatric setting and estimate the

Screening practices Surveys were completed by 393 (73%) of the 540 eligible physicians who were actively practicing medicine and who saw children in their practices. Among respondents, 55% were general or family practitioners, 21% were paediatricians, 13% practised emergency medicine and 11% practised other streams. Nearly one-quarter (23%) of respondents worked for the Indian Health Service or Native Health Corporations, 43% were in private practice, 15% were in hospital-based/urgent care settings and 7% were on a military base. Regarding representativeness of the study population, while a comparison between respondents and non-respondents was not possible, the survey was mailed to all physicians in Alaska that were licensed to practice in medical specialties where children were seen as patients and a respectable response rate was achieved. Two-thirds (66%) of respondents had general training on DV in the past 3 years, nearly one-half (49%) had

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Behavioral Health

Table I. Physicians’ ratings of perceived barriers to screening for domestic violence (DV) Perceived barrier

Major barrier (%)

Minor barrier (%)

Not a barrier (%)

Difficult to talk to mother alone

18

52

30

Not comfortable screening in the presence of children

11

50

39

Lack of enough time Inadequate training

20 8

43 35

37 57

Frustrating to screen because mothers do not disclose

19

46

35

Cultural barriers

14

49

37

Uncertain how identifying DV will help mother or children

5

17

78

Identifying DV may require report to child protective services

6

27

67

training on the effects of DV on children and 47% had training on the impact of trauma on early brain development. Nearly one-fifth (18%) of physicians estimated that 1 in 5 children seen in their practices were living in violent households. While the majority of respondents were screened routinely (most of the time or always) for DV when a mother presented with an injury (88%) or child abuse was suspected (95%), routine screening was less frequent at initial visits (16%), well child visits (11%) and when providing counselling/anticipatory guidance to mothers of new-borns (16%).

Perceived barriers to screening and perspectives Physicians’ ratings of perceived barriers to screening mothers for DV at paediatric visits are shown in Table I. Time constraints (20%), frustrations about screening due to mothers not disclosing abuse when asked (19%) and difficulties with being able to talk privately with mothers (18%) were rated as the 3 most common major barriers to screening. Nearly all (98%) of the respondents agreed that exposure to DV was an important health issue for children and the majority (82%) indicated that they had a professional responsibility to screen mothers for DV when providing health care to children. There was nearly unanimous agreement among physicians that helping a mother who is being abused can make a difference in the lives of their children (99%), and that children living in homes with DV are more likely to be victims of child abuse (99%). We also evaluated the independent contribution of the variables in predicting whether physicians screened at initial and well child visits. Physicians who agreed that they have a responsibility to screen mothers at paediatric visits were 2.7 times more likely to screen mothers at initial and well child visits compared to physicians who did not agree with this statement (95% CI 1.35.5).

Physicians who had recent training on the effects of DV on children were twice as likely to screen mothers at initial and well child visits compared to physicians who did not have training in the past 3 years (OR 2.1; 95% CI 1.23.8). Physicians who reported that they were not comfortable screening when children were present was predictive of not screening mothers at initial and well child visits (OR0.2; 95% CI 0.070.39).

Discussion While a majority of paediatricians agree that they have a responsibility to screen for DV at paediatric visits, and that DV is an important children’s health issue, many physicians do not screen routinely at paediatric visits. Commonly perceived barriers to screening for DV in the paediatric setting, which have been reported elsewhere in the literature, were not predictive of screening in this study. Training appears to have an important role in physicians’ understanding of DV as a paediatric issue and maternal screening practices. Since physicians’ selfreported screening practices varied considerably by the type of paediatric visit, future studies should examine barriers to screening within the context of the type of paediatric visit.

References 1. American Academy of Pediatrics. Clinical report intimate partner violence: the role of the pediatrician. Pediatr. 2010; 125:1094100. 2. Holt S, Buckley H, Whelan S. The impact of exposure to domestic violence on children and young people: a review of the literature. Child Abuse Negl. 2008;32:797810. 3. Erickson MJ, Hill TD, Siegel RM. Barriers to domestic violence screening in the pediatric setting. Pediatr. 2001;108:98103. *Linda Chamberlain Email: [email protected]


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Conference Abstracts CULTURALLY APPROPRIATE MENTAL HEALTH SERVICES IN CANADA’S NORTH A. Drossos University of Toronto For many of the indigenous people in Canada’s North the notion of mental illness was unheard of prior to colonization, and even today many do not relate well to the concept especially as a separate diagnostic entity. The holistic view of health - including the spiritual, physical, emotional and mental - is more in line with indigenous ways of knowing. Furthermore, healthcare service delivery in Canada’s North is an ongoing challenge. In most communities, the only healthcare facility is a nursing station staffed by highly qualified nursing professionals, with only infrequent fly-in visits by physicians. Access to specialist physicians, including psychiatrists, is even more rare. Local mental health services are almost nonexistent, not to mention ones that are culturally appropriate and designed with Inuit Qaujimajatuqangit in mind. Currently, Inuit who need specialized mental health services generally travel South to access them, or otherwise go without them altogether. For Inuit from Nunavut, most of the Inuit specific mental health services are in the nation’s capital, Ottawa. Not only is Ottawa a great distance from home for most Inuit, but culture shock, a lack of family and community supports and many other differences are major barriers to healing. Many have recognized that the gap in mental health services in the North needs to be addressed. Using a combination of personal experience through travel and clinical work in Nunavut, a literature review of both mental health issues and mental health services design and provision in other Indigenous areas around the world, and informal input from Inuit around the country a description of possibilities for innovative, comprehensive and culturally appropriate mental health services for Inuit, by Inuit and in Inuit communities is described. These include acute, chronic, rehabilitative as well as community-based services for the entire lifespan that use a collaborative approach. Contact: A. Drossos ([email protected])

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SMOKING CESSATION IN NUNAVUT, CANADA: WHAT DO INUIT HAVE TO SAY ABOUT QUITTING? M.J. Costello1, J. Garcia1, P. McDonald1, M. Doucette2, A. Kronstal2, A. Korgak2, M. Charron2, G. Osborne2, I. Sobol3 1 University of Waterloo, 2Government of Nunavut, 3 Government of Manitoba Objectives. To report on Nunavummiut Inuit attitudes toward quitting smoking and their experiences with quitting. Perceived barriers to quitting are also reported. Methods. A qualitative study that consisted of 26 focus groups and 5 individual interviews was conducted from May to June 2010 with 113 participants aged 16 years and over, from 3 communities in Nunavut. Results. Participants indicated there was interest within their communities to quit smoking; however, actual quitting was less common than desirable. Most common reasons for wanting to quit included the risk of developing smoking-related health effects, knowing someone who suffered from a smoking related health effect, the cost of cigarettes, and having been told to quit by a medical doctor. Many reported it was difficult to quit and stay quit; relapse was considered common. Those who had tried to quit often reported doing so on their own using various distraction techniques (e.g., keeping busy, chewing gum, playing sports). Some had also tried nicotine replacement therapies (e.g., nicotine gum or patches). Most common barriers to quitting included the social acceptance and widespread use of tobacco. Emotional triggers such as boredom, stress, and depression, as well as nicotine dependence or addiction were also reported as barriers. Many indicated few formal quitting supports were available within their communities to help those who wanted to quit; however, family, friends and Elders were perceived as important supports. Conclusions. These findings provide insight into the barriers Inuit face when trying to quit smoking in Nunavut and will help to inform the development of more culturally appropriate smoking cessation interventions within the Territory. Already a media campaign has been implemented in Nunavut to create a local dialogue


Behavioral Health

on smoking, encourage quit attempts, and support those who choose to quit. Contact: M.J. Costello ([email protected])

THE SIGNIFICANCE OF SMOKING ON DAILY LIFE IN A GREENLAND VILLAGE INTERVIEW WITH SMOKERS

A.B. Jensen1, L. Hounsgaard2 1 Dronning Ingrids Hospital, Nuuk, 2Greenland Institute of Nursing and Health Science, University of Green

CONTRASTING SOCIAL NORMS AND POLICIES AROUND SECONDHAND SMOKE IN DIFFERENT REGIONS OF ALASKA E. Peterson1, J. Dilley2, M. Bobo3, K. Pickle2 1 State of Alaska Department of Health & Social Services, 2 Program Design & Eval Svcs, Multnomah Cty/OR Hlth Authority, 3State of Alaska DHSS, Tobacco Prevention & Control

Background. Smoking-related conditions, such as COPD, cardiovascular disease and lung cancer, are common in Greenland. Factors such as age, gender, cigarette use, restricted smoking at home and socioeconomic determinants are well-known predictors for smoking and smoking cessation. From 1999 and through to 2005, the fall in the number of smokers stagnated and in 2005 66% of the adult population were smokers, despite widespread smoking cessation campaigns. It is therefore imperative to identify the factors that influence the lack of smoking cessation to enable better targeting of preventive work with smoking. Objectives. To investigate the meaning of smoking on the daily life of unskilled residents of a small town in Northern Greenland. Materials and Methods. An ethnographic field study is being undertaken, including participant observation and semi-structured interviews with health professionals and smokers. The analysis of the empirical data is being conducted on three analysis levels: naive reading, structural analysis and critical interpretation, using a phenomenological-hermeneutic text analysis method. Results. Having time on one’s hands can be a factor in smokers remaining as smokers. It appears that smokers nowadays consider themselves to be stigmatised. This may be one reason for wanting to stop smoking. Smokers ask for how to quit and ask for help to give up smoking in terms of medical treatment for withdrawal symptoms. It appears that male and female smokers have different perceptions when they evaluate their health as being bad. For women it is frequently based on stress, and for men on physical illness. Serious illness or being pregnant appear to be triggers to consider giving up smoking. Severe withdrawal symptoms and knowledge about how one gives up smoking are barriers to participants achieving their goal. Conclusion. Prevention initiatives should be targeted at all smokers and a smoking cessation service should be developed, where smokers are supervised and receive medical treatment for withdrawal symptoms.

Creating laws and policies that protect the public from exposure to secondhand smoke (SHS) is a highly effective tobacco control intervention. Formal policies can be enacted by independent facilities, or on a municipal or statewide level that covers all facilities. SHS exposure might also be limited by social norms, where communities have ‘‘unwritten rules’’ that smoking around other people is not acceptable. In Alaska, most communities are rural and many are not incorporated as municipalities. Some may have few buildings where the community gathers. To determine whether there were differences in the presence of current policies (formal or informal), and social norms, the Alaska Tobacco Prevention and Control Program developed a series of questions about the presence of three facilities that are commonly found even in very small communities (schools, hospitals and clinics), and whether smoking was allowed there. These questions were added to the 2011 Alaska Behavioral Risk Factor Surveillance System (BRFSS), an ongoing statewide telephone health focused survey of Alaska’s adult population. The BRFSS already contained questions about SHS exposure and perceived harm of SHS exposure. We used preliminary data to explore differences among urban, hub and rural Alaska communities: presence of facilities, whether people thought there were rules that banned smoking, whether they had seen others smoking in those facilities, perceived smoking prevalence in the community, perceived harm of SHS, and exposure to SHS. Many rural communities do not have large numbers of public buildings where policies could be enacted. Our findings suggest that the policies and social norms that protect nonsmokers from secondhand smoke are not as strongly in place in Alaska’s rural communities. This may mean that protective policies have not been adopted as readily, or that design and dissemination of policies needs to be adapted to be more relevant to rural Alaska communities.

Contact: A.B. Jensen ([email protected])

Contact: E. Peterson ([email protected])


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ASSOCIATION OF ADH1B, ADH1C, PDYN AND DRD4 GENE POLYMORPHISMS WITH ALCOHOLISM IN RUSSIAN POPULATION OF WEST-SIBERIAN REGION A. Marusin, K. Simonova, N. Bokhan, V. Stepanov Institute of Medical Genetics, SB RAMS Alcoholism is the widely-distributed addictive distress with polygenic inheritance and heritability of 3060%. Fife polymorphic loci in ADH1B (rs1229984), ADH1C (rs1789920), PDYN (rs2235749 and 68 bp VNTR in 3’UTR), DRD4 (120 bp VNTR in 5’-UTR) gene were investigated in alcoholics (n 238) and control group (n365). The observed genotype frequencies correspond to expected in Hardy-Weinberg equilibrium for all loci of both groups. The statistically significant low LD observed between ADH genes. LD coefficients (d) were 0.014 in controls and 0.010 in alcoholics (p 0.02 and 0.06, accordingly). Strong LD for PDYN gene polymorphisms were detected (pB10 6; d 0.082, and 0.070 in control and alcohol groups, respectively). Reduced risk of alcohol dependence was revealed for ADH1B*A allele carriers (OR0.42; (95%) CI 0.23 0.79; p 0.003) and elevated risk was detected for ADH1C*C allele carriers (OR1.42; (95%) CI 1.09 1.85; p 0.008). No associations of DRD4 and PDYN gene polymorphisms with alcoholism were shown. This work was supported by the Russian Foundation for Basic Research (project no. 11-04-98069-r_sibir’_a). Contact: V. Stepanov ([email protected])

VIOLENCE AND ALCOHOL RELATED EMERGENCIES IN THE GREENLANDIC HEALTH CARE SYSTEM J. Wilche1, J. Nexoe2, B. Niclasen1, A. Kjeldsen1, C. Fargemann3, A. Munk4, J. Lauritsen3 1 Ministry of Health, Government of Greenland, 2 Research Unit Og General Practice, Institute of Public Healy, 3Accident Analysis Group, Odense Universities Hospital, 4Audit Projest Odense, Research Unit of General Practice, Ins Objectives. The purpose of this study was to describe emergencies admitted to the Greenlandic Health Care System and to which extent were admissions caused by alcohol abuse or violence. Furthermore, we examined to which extent data on emergencies in Greenland could be registered in a reliable way by simple means. Study design. Descriptive, non-interventional study. Methods. Registration of alcohol and/or violence associated emergencies were presented to 15 out of 17 Greenlandic health districts in the 17-days period from 21 May to 7 June 2010.

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Results. In the registration period of 17 days, 2,403 emergencies were registered. In 10% of cases the patients were clinically alcohol intoxicated. When reason for presentation were mental or social problems, attempted suicide, accidents, or violence 24%, 50%, 15% and 59% were intoxicated respectively. Alcohol intoxication was significantly more often associated with advanced treatment (e.g. evacuation, hospitalization, or follow up by doctor or nurse). Conclusions. This study confirms that violence and alcohol related emergencies put a considerable strain on the Greenlandic Health Care System. Due to short the duration of observation we have not been able to describe the actual size of the problem in detail. Nor was it possible to estimate whether this problem is more pronounced in Greenland than in other countries such as Denmark. Contact: J. Wilche ([email protected])

TOWARDS AN EVALUATION FRAMEWORK FOR COMMUNITY-BASED FASD PREVENTION AND FASD SUPPORT PROGRAMS M. Van Bibber1, C. Hubberstey1, N. Poole2, D. Rutman1, S. Hume1 1 Nota Bene Consulting Group, 2BC Centre of Excellence for Women’s Health This presentation will share findings from the ‘‘Toward an Evaluation Framework for Community-based FASD Prevention Programs’’ project, which aims to identify promising evaluation methods and create common evaluation frameworks and tools for FASD prevention and supportive intervention programs serving pregnant women and mothers, and youth and adults living with FASD. The importance of strong evaluation in the development and delivery of FASD-related programs and services cannot be overstated. Our project came about following recognition of a growing desire to share what has been learned about the design and delivery of FASD prevention and intervention programming i.e., what works, for whom, and in what context - and to build understanding about various approaches to evaluation. The project’s approach is highly collaborative and has been guided by a 13-person national Advisory Committee. Following an extensive review of existing frameworks, methods and indicators of success being used by FASD prevention and support programs, in fall 2011 the project team facilitated day-long consultations with program providers and researchers in three regions of Canada. We received input on key outcomes, indicators, and respectful and effective approaches and tools for collecting evaluation and outcome data. Based on information gathered to date, the team has created three Conceptual Maps (one for FASD Prevention programs, one for


Behavioral Health

FASD Supportive Intervention programs, and one for FASD programs in Aboriginal communities). The Maps have been developed as tools for conceptualizing evaluation and describing the connection between program philosophy and program approaches/activities, formative outcomes, and client, community, and systemic outcomes. In this conference session, we will present the conceptual roadmaps, and session participants will be invited to share feedback and discuss their experiences of promising practices in evaluation particularly within a Northern and systemic outcomes. In this conference session, we will present the conceptual roadmaps, and session participants will be invited to share feedback and discuss their experiences of promising practices in evaluation particularly within a Northern and systemic outcomes. In this conference session, we will present the conceptual roadmaps, and session participants will be invited to share feedback and discuss their experiences of promising practices in evaluation particularly within a Northern and Indigenous context, as well as the policyrelated and ethical implications for FASD program development, delivery and evaluation. Contact: M. Van Bibber ([email protected])

SAMI VALUE PATTERNS K.L. Hansen Centre for Sami Health Research, Universtity of Tromsø Objectives. To study and contrast personal values in ethnic minority (Sami) and ethnic majority (Ethnic Norwegian) populations in Norway. Study design. A population-based, cross-sectional study called the SAMINOR study was carried out in 2003-04 in areas of populations with mixed ethnicity. Method. From 24 municipalities, a total of 12,623 subjects between the ages of 36 and 79 were included in the analysis of personal values. The survey instrument consisted of a 19-item questionnaire and the analysis was based on responses from 10,268 Ethnic Norwegian and 2,355 Sami participants. Associations between personal value variables were assessed using principal component analysis. Conclusion. Four distinct value patterns where identified in the Sami population. The four dimensions reflect important aspects of today’s Sami society. Results. From the 19 values, Sami respondents held the following five personal values in the highest regard: being in touch with nature; harnessing nature through fishing, hunting and berry-picking; preserving ancestral and family traditions; preserving traditional Sami industries and preserving and developing the Sami language. On the other hand, Sami respondents’ least important values included modern Sami art and the Sami Parliament (Sametinget). Four dimensions associated with values

were identified: ‘‘Traditional Sami Values’’, ‘‘Modern Sami Values’’, ‘‘Contact with Nature’’ and ‘‘Feeling of Marginalization’’. Traditional and Modern values were both characterized by significantly higher scores among females, the lowest age bracket and those who considered themselves Sami (not including those who considered themselves to be of mixed Sami/Ethnic Norwegian background). Within the Traditional Sami Values dimension, higher scores were also recorded in participants who were married or cohabiting, living within the Administrative Area of the Sami Language, satisfied with ‘way of life’ and members of the Laestadian Church. The Modern Sami Values dimension was also characterized by higher scores among participants with high household incomes. The Contact with Nature dimension was characterized by significantly higher proportions of Sami (excluding participants of mixed Ethnic Norwegian/ Sami background), married or cohabitants, and participants content with their way of life; age, living area and household income was found to be insignificant variables within this dimension. Feeling of Marginalization was characterized by: significantly greater proportions of males; of working age; living outside the Administrative Area of the Sami Language; considering oneself to be Sami (excluding mixed ethnic background); low household income; and dissatisfaction with way of life. Contact: K.L. Hansen ([email protected])

INUIT WELLNESS IN ACTION: AN UPDATE ON THE ALIANAIT MENTAL WELLNESS ACTION PLAN E. Ford Inuit Tapiriit Kanatami Inuit Wellness In Action. Alianait Mental Wellness Action Plan from the macro to the micro! The Alianait Inuit specific Mental Wellness Task group was formed to develop an Inuit Mental Wellness Plan to support the First Nations and Inuit Wellness Advisory Committee’s (MWAC) ‘‘Strategic Action Plan for First Nations and Inuit Mental Welllness’’. The Alianait Task Group is comprised of representatives from Inuit Tapiriit Kanatami (ITK), First Nations and Inuit Health Branch (FNIHB) of Health Canada, land claim organizations, national Inuit organizations and governments with Inuit populations. The Alianait Inuit-specific Mental Wellness Task Group created an Action Plan for Inuit mental wellness in 2007 in partnership with the four Inuit land claim regions which identified five priority goals. Nationally Inuit define mental wellness as an all-inclusive term encompassing mental health, mental illness, suicide prevention, violence reduction and reduction of substance abuse and addictions. What does an Inuit specific


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Mental Wellness Action Plan look like in motion for addictions and suicide prevention? This presentation will examine the action plan in two specific areas of Inuit Mental Wellness: addictions and suicide prevention. For addictions, the Action Plan informs the development of an Inuit Nunangat Addictions process in the context of Alianait and the federal renewal of the National Native Alcohol and Drug Abuse Program. For suicide prevention, the development of the National Inuit Suicide Prevention Strategy uses Alainait Action Plan as a creative cornerstone. Both specific areas under discussion will examine how this Action Plan informs movement at the community, regional and national levels. As well how all three levels work in concert to produce results for Inuit in their communities, regions and nationally in both a suicide prevention and addictions context. Contact: E. Ford ([email protected])

SUICIDE IN ALASKA: EXPLORING INTER- AND INTRA-REGIONAL DIFFERENCES J. Craig1, D. Chromanski Hull-Jilly2 1 Alaska Native Tribal Health Consortiu, Department of Health and Social Services

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Background. Alaska has consistently had one of the highest suicide rates in the United States (U.S.). Alaska Native people have consistently had suicide rates higher than any other racial/ethnic group in the U.S. Inter- and intra-regional variation has not previously been explored. Methods. Descriptive analyses were conducted using Alaska Violent Death Reporting System data for 2003 through 2008. Suicides among Alaska Native and Alaska non-Native people by region were examined. Communities within a region were divided into hub or non-hub. Hub communities were defined as the city or cities where the majority of the region’s population resides and/or where major health, tribal government, educational, and commercial resources are located. Results. The rate of suicide among Alaska Native people was highest in the Northwest Arctic and lowest in the Southeast tribal health region (93.1 versus 20.2 per 100,000 persons). The rate of suicide was highest for Alaska non-Natives in the Yukon-Kuskokwim and lowest in the Southeast tribal health region (27.1 versus 15.4 per 100,000 persons). Examining the regional hub versus non-hub communities separately, the rate of suicide for both Alaska Native and Alaska non-Native people was significantly higher in the non-hub communities than in the hub communities (p B0.01). Conclusions. Alaskan non-hub communities had higher rates of suicide than hub communities. Previous studies have linked low population-density areas with isolation, reduced access to resources such as behavioral health

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counselors, decreased likelihood of intervention if a person was experiencing suicidal ideation and higher suicide rates. Further research is needed to explore innovative ways to provide behavioral health resources in non-hub communities in order to improve future suicide prevention efforts. Contact: J. Craig ([email protected])

COMMUNITY PERSPECTIVES ON PROTECTIVE AND CONTRIBUTING FACTORS IN ALASKA NATIVE/AMERICAN INDIAN SUICIDE J. Shaw, D. Dillard Southcentral Foundation The suicide rate among Alaska Native/American Indian (AN/AI) people is more than twice the rate of non-native people in the state. Suicide is a significant problem in all Alaska Native communities, but everyone is not equally affected. There are regional disparities in AN/AI suicide rates across Alaska, with rates ranging from 80 suicides per 100,000 people in the Northern region to less than 30 in Southern regions. This variability suggests potential differences in underlying risk and protective factors for AN/AI suicide between regions. Despite abundant epidemiological data on suicide risk and protective factors, we know little about meaningful differences in these factors across regions and their implications for understanding regional variation. This study investigated the perspectives of AN/AI people on factors affecting suicide in their communities. We used focus groups in three communities to ask AN/AI adults about local risk and protective factors and how they affect regional suicide rates. We also interviewed community members who work in education, healthcare, law enforcement, clergy, and tribal leadership to gain professional perspectives on risk and protective factors. Preliminary findings suggest that comprehensive, community-based, and ecological approaches to suicide prevention, intervention and ‘‘postvention’’ are needed to foster ‘‘groundedness’’ and connectivity among individuals at risk, build protective communities, and reduce suicide in all AN/AI communities. Contact: J. Shaw ([email protected])

DEVELOPMENT OF SUICIDALITY AMONG SAMI REINDEER HERDERS AS A RESULT OF WORK-RELATED STRESS A. Silviken Sami National Center for Mental Health/Sami Health Research Aim. To discuss the development of suicidality as a result of work-related stress in reindeer herding management in view of Mark Williams’ model ‘‘Cry of Pain’’.


Behavioral Health

Background. The Sami people is an indigenous group with their own culture and native language residing in the arctic part of Scandinavia. Traditional Sami reindeer herding is small business on a national scale, but it is an important symbol and bearer of Sami culture. There are several aspects of reindeer herding that can cause workrelated stress. Reindeer herding management is characterized by hard work of physical and mental character, and they work under challenging climatic conditions. In recent times we see additional strains due to internal and external conflicts, such as access to grazing land, poor grazing conditions, mixing of herds, development of grazing lands, and predator problems. The suicide rates in the general Sami population in Northern Norway can be considered as moderate (19/100 000, 19701998). However, it is well known that in some Sami communities there has been a high prevalence of suicide during the last three decades, and that several villages have experienced suicide clusters. Previous research has indicated that the reindeer herding Sami have been protected against suicide, while recent studies show an increased incidence of suicidal thoughts and plans among Swedish reindeer herding Sami. Method. In the presentation, the development of suicidality as a result of work-related stress in reindeer herding management, will be understood in view of Mark Williams’ model ‘‘Cry of Pain’’. Conclusion. Work-related stress due to internal and external conflicts may cause an experience of entrapment among vulnerable Sami reindeer herders, and thus increase the risk of development of suicidality. Contact. A. Silviken ([email protected])

SUICIDE AMONG YOUNG ALASKA NATIVE MEN: COMMUNITY RISK FACTORS AND ALCOHOL CONTROL M. Berman University of Alaska Anchorage Objectives. We examined community risk factors that explained variation in suicide rates among young rural Alaska Native men, evaluating the effectiveness of local alcohol control as a public health policy for reducing the historically high vulnerability of this population. Methods. We compiled suicide data, alcohol control status, and community-level social, cultural, and economic characteristics for 178 small rural Alaska communities over a 28-year period. Poisson regression equations, taking into account the endogenous community selection of alcohol control, explained variation in suicide rates for Alaska Native males age 1534 as a function of alcohol control and community characteristics. Results. Young male suicide rates were higher in communities prohibiting alcohol importation under state

law, but the effect was not significant after controlling for other community characteristics. More remote communities, those with fewer non-Natives, and those with evidence of cultural divides had higher suicide risks. Communities with higher incomes, more married couples, and traditional elders had lower risks. Conclusion. Alcohol control appears ineffective as a prevention measure. However, communities have limited means to pursue economic and cultural development strategies that appear more promising. Contact. M. Berman ([email protected])

AN EXPLORATION OF SUICIDE RISK FACTORS IN ALASKA 2003 2006: COMBINING THE ALASKA TRAUMA REGISTRY AND ALASKA INJURY PREVENTION CENTER DATA

T. Sunbury1, N. Luvsandagva2 1 Institute for Circumpolar Health Studies, 2University of Alaska Anchorage Objectives. Suicide rates in Alaska are approximately twice as high as in the general US population and about four times higher for 2029 year olds. Even though variations exist in the rate of suicide across geographical location, gender, and mechanism of injury much of the past research findings have focused on univariate and bivariate statistics ignoring the complicated multifactorial relationships between and among these risk factors. Multivariate research is needed to assess the importance of differentiating subgroups within populations, and the distinction between populations and communities in understanding causes of disparities in suicide rates. The purpose of this study was to provide further examination of smaller-scale (local) analysis of spatial characteristics and identify spatial-temporal trends in suicidal behaviorrelated hospitalizations. Methods. The Alaska Trauma registry (ATR) was searched for hospitalizations with injury cause listed as suicidal. Information concerning each inpatient included: gender, age, ethnicity, occupational, type of injury, injury mechanism, home of record, principle diagnosis, and trauma code. Rates were age-adjusted and calculated using the 2000 and/or 2010 U.S. Census data and mapped to the local level using ArcGIS v.10 software. Additional data on completed suicides were obtained from the Alaska Injury Prevention Center (AIPC) for 2003 2006 and included information on: gender, age, employment, injury mechanism, toxicity, and blood alcohol concentration. Results. From 20032006, the ATR reported 2,583 patients that were hospitalized for suicidal injury intent, whereas AIPC reported 426 completed suicides during the 36 month study period. More women were represented in the ATR dataset, while the ratio of


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men-to-women was 4:1 in the AIPC data. Spatialtemporal trends were consistent between the two data sets. The ATR suggested that patients engaged in an incident of interpersonal argument/violence before attempting suicide. Conclusions. Geographic location is a substantial suicide risk factor, even controlling for month (seasonality). Suicide prevention, gun safety, and treatment enhancements should specifically address high-risk locations. Further study into the circumstances prior to suicide attempt is needed to fully understand the geographical disparities and to adapt and implement prevention programs. Contact. T. Sunbury ([email protected])

THE VILLAGE WELLNESS PROJECT: BUILDING COMMUNITY RESILIENCE AND PREVENTING SUICIDE IN RURAL ALASKA P. de Schweinitz1, C. Nation1, C. DeCou2, T. Stewart2, J. Allen2 1 Tanana Chiefs Conference, 2University of Alaska The Village Wellness Project of Tanana Chiefs Conference (TCC, Alaska) has three primary purposes: 1) to empower villages to build unique programs for resiliency and suicide prevention; 2) to allow individual villages to shape the larger system of care at TCC; and 3) to develop an (indigenous) Athabaskan theory of community wellness and suicide prevention. In this presentation we discuss our process of wellness team building (and lessons learned), the gun safe program, the collection of focus group data, the analysis by means of modified grounded theory, and our preliminary research findings. While our findings vary by village, preliminary data suggest that rural Alaskans living in Native predominant communities 1) are willing to discuss and prioritize issues of mental well-being and want to take strong measures to reduce suicide; 2) wish to focus on increasing community safety; 3) are concerned about cultural loss; 4) wish to increase local professional counseling services; and 5) want to increase local economic opportunities for recent high school graduates. Contact. P. de Schweinitz ([email protected])

CULTURAL INTERVENTION FOR SUICIDE PREVENTION: THE QUNAGSVIK PROJECTS WITH INDIGENOUS YOUTH IN ALASKA J. Allen1, W. Charles2, S. Rasmus2 1 University of Alaska Fairbanks, 2Center for Alaska Native Health Research Indigenous understandings of youth development and the change process serve as point of departure in cultural intervention rooted in indigenous theory. Elluam

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Tungiinun (toward wellness) is a cultural program for the prevention of youth suicide and alcohol abuse for rural Yup’ik youth in Alaska ages 1218 and their families. The intervention developed out of a long-term CBPR collaboration between members of an Alaska Native community and university researchers. One aim of Elluam Tungiinun was to ground the intervention in local Indigenous theory to create contexts to experience Ellangneq (awareness) through its activities. This presentation provides an example of two activites, Murilkelluku Cikuq (watch the ice), which teaches river ice safety, and the Qasgiq (men’s house), which teaches a model of community organizing and decision making. We describe how this indigenous process became the basis for intervention development and a flexible adaptive process for intervention in other communities, which our co-researchers named Qungasvik (toolbox). Effective intervention for indigenous communities is adaptive to local cultural context, and based on the function of the activity as event in system, not specific components or form of intervention activity. The basis of intervention is the protective factors embedded in the cultural values with the activity. Selected outcomes are described and intervention is understood as a community development process. Please include in symposium on ‘‘Community Directed Suicide Prevention in the Circumpolar North’’ Contact. J. Allen ([email protected])

INTERVENTION AMONG ALASKA NATIVE PEOPLE: AN EVALUATION OF ASIST H. Strayer Alaska Native Tribal Health Consortium Introduction and Background. Alaska Native people have suicide rates nearly four times the national average. The Applied Suicide Intervention Skills Training (ASIST) is an evidence-based program training community members to recognize and help people at risk of suicide. Starting in 2008, trainers associated with the Alaska tribal health system began ASIST trainings. To date, 1,306 people have received this training from 50 trainers in the Alaska Tribal Health System. Methods. To evaluate the effectiveness of these trainings, we surveyed ASIST participants by phone at least nine months after their training. The questionnaire asked about their experience using ASIST to intervene, changes in comfort levels talking about suicide, how appropriate ASIST was for their community, and what type of support they needed. Those contacted were a convenience sample of participants from rural and urban communities. Results and Discussion. The questionnaire included 30 questions and averaged 20 minutes to complete. We completed questionnaires with over 100 participants: data analysis is pending. Final data will include percentage of


Behavioral Health

participants who are Alaska Native people; that live in rural communities; that work in a profession associated with suicide prevention; that had suicide intervention experience prior to taking ASIST. We will report the number of suicide interventions ASIST participants were involved in, and what proportions took place in rural communities and at work. We will determine the proportions of participants who felt ASIST improved their ability to talk about suicide and recommended that other community members should take ASIST. Preliminary data show the most frequent support requested was refresher training. We will provide data on difficulties perceived with ASIST, such as how many participants felt the twoday training was too long. Conclusion. These results support using ASIST as a suicide intervention tool in Alaska. We will explore refresher training for participants. Contact. H. Strayer ([email protected])

THE ROLE OF COMMUNITY CONSULTATIONS IN SUICIDE PREVENTION RESEARCH IN LABRADOR N. Pollock1, M. Jong2, S. Mulay3, K. Chaulk4, J. Wight4, A. Al-Krenawi5 1 Memorial University of Newfoundland, 2LabradorGrenfell Health & MUN, 3Faculty of Medicine, MUN, 4 Labrador Institute, MUN, 5School of Social Work, MUN Background. In Canada, many Aboriginal communities struggle with a disproportionate burden from suicide. Despite substantial mobilization to prevent suicide, it persists as an urgent health problem in many northern areas, including Labrador. Two provincial studies have found that compared to Newfoundland, Labrador had higher rates of suicide mortality [superscript ‘‘1’’ for end note] and hospitalization for attempts. [superscript ‘‘2’’ for end note] Another study reported that the suicide rate in Nunatsiavut communities is twice as high as other Inuit settlement areas. [superscript ‘‘3’’ for end note] In response to local concerns, stakeholders in Labrador have requested research to help identify at-risk groups, develop effective prevention programs, and improve access to mental health services. Methodology. To address this need, Aboriginal governments, the regional health authority, and university researchers have initiated a suicide prevention research program. The primary objectives are to understand local risk and protective factors for suicidality and translate this into enhancing programs and services. The partners are undertaking a community consultation as the first step in the research process to learn about local experiences and priorities, build relationships, and design future studies. This consultation involves multiple activ-

ities including workshops with elders and youth, and key informant and focus group interviews with community leaders and health professionals. Results. The consultations are taking place during the winter and spring of 2012, therefore the specific priorities and themes are still emerging. The consultation will inform a multi-year research plan. Conclusion. This presentation will provide a overview of the community consultation process and identify the themes and priorities that emerge from it. We will also present our research plan and lessons learned about community consultations. This is meant to foster discussion and seek. Works Cited. 1 Edwards N, Alaghehbandan R, MacDonald D, Sikdar K, Collins K, Avis S. Suicide in Newfoundland and Labrador: A linkage study using medical examiner and vital statistics data. Can J Psychiatry. 2008;53:252 259. 2 Alaghehbandan R, Gates KD, MacDonald D. Suicide attempts and associated factors in Newfoundland and Labrador, 19982000. Can J Psychiatry. 2005;50: 762768. 3 Hicks J. Toward more effective, evidence-based suicide prevention in Nunavut. In: Abele F, Courchene TJ, F., Seidle L, and St-Hilaire F, eds. The Art of the State IV Northern Exposure: Peoples, Powers and Prospects in Canada’s North. Montreal: The Institute for Research on Public Policy; 2009:467. Contact. N. Pollock ([email protected])

THE HUSLIA WELLNESS TEAM DOCUMENTARY: SUICIDE PREVENTION THROUGH COMMUNITY EMPOWERMENT P. de Schweinitz1, C. Nation1, C. Sam2 1 Tanana Chiefs Conference, 2Huslia Tribal Administration The Huslia Village Wellness Team seeks to empower villages through a community-based participatory research process. Near the end of our first year in the village of Huslia, we asked the leader of the Wellness Team what more could be done. She suggested that we create a film as a means of disseminating knowledge about wellness team development. The film, shot in two days and edited over several weeks by a professional filmmaker working pro bono, has become a method of opening conversations in other villages about suicide, mental health, and wellness team development. In this presentation we will introduce our methods of community work, show the 40 minute film, and answer questions. Contact. P. de Schweinitz ([email protected])


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CHAPTER 4. Chronic Disease

CHRONIC DISEASE æ

Chronic disease * Introduction Meera Narayanan

elcome to the chronic disease section of the ICCH15 Proceedings. The major themes observed during ICCH15 included cancer, cardiovascular disease (CVD) and issues related to overweight/ obesity, including diabetes. Within the broad category of cancer, topics included surveillance data on human papilloma virus (HPV) cancer rates among Alaska Native women, innovative approaches to colorectal cancer screening among Alaska Native people, gastric cancer in Siberia and biomarkers for ovarian cancer and eye tumour development in Russia. Arts-based education and digital storytelling for cancer awareness and education among Alaska Native people push the boundaries of traditional methods of conveying health information to patients and communities. There were many abstracts and manuscripts from the Russian arctic dealing with several facets of CVD. The association of social and mental health factors such as marriage, income, family discord and depression with heart attack and stroke provide new and provocative perspectives on these conditions. Differences in stroke rates between indigenous and non-indigenous people in Yakutia, clinical indicators of CVD in northern people and the increasing prevalence of hypertension in the north were some of the major topics of interest within this theme. Within the field of diabetes research, topics highlighted during the proceedings include diabetes prevalence in a western Alaska region, amputations among Alaska Native people, genetic markers associated with diet in western Alaska and Canadian findings on immune action

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in type 2 diabetes. The significance of body mass index cut-offs using different anthropometric measurements is also addressed. The breadth of the impact of chronic disease is emphasized in several studies not directly related to CVD. Emerging trends on the prevalence and treatment of osteoporosis and obstacles and challenges pertaining to cochlear implants in Greenland are addressed in the proceedings, attesting to the diversity of issues that fall under the broad spectrum of chronic disease. Many of the abstracts, extended abstracts and manuscripts you come across in the next several pages open the doors for further exploration of interesting hypotheses and associations discussed by the authors. As people live longer and the prevalence of chronic disease increases due to lifestyle and environmental factors, we look forward to sustainable, culturally relevant intervention programs that address many of the chronic diseases we heard about at the ICCH15. Finally, I thank Dr. Cynthia Schraer for her scholarly counsel and sage comments throughout the editorial process, as well as with the overall outline of this Introduction.


Meera Narayanan Diabetes Epidemiologist Alaska Native Tribal Health Consortium Email: [email protected]

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Bridging storytelling traditions with digital technology Melany Cueva1*, Regina Kuhnley1, Laura J. Revels1, Katie Cueva2, Mark Dignan3 and Anne P. Lanier1 1

Alaska Native Tribal Health Consortium, Anchorage, AK, USA; 2Institute of Social and Economic Research, University of Alaska, Anchorage, AK, USA; 3Markey Cancer Center, University of Kentucky, Lexington, KY, USA

Objective. The purpose of this project was to learn how Community Health Workers (CHWs) in Alaska perceived digital storytelling as a component of the ‘‘Path to Understanding Cancer’’ curriculum and as a culturally respectful tool for sharing cancer-related health messages. Design. A pre-course written application, end-of-course written evaluation, and internet survey informed this project. Methods. Digital storytelling was included in seven 5-day cancer education courses (May 20092012) in which 67 CHWs each created a personal 23 minute cancer-related digital story. Participant-chosen digital story topics included tobacco cessation, the importance of recommended cancer screening exams, cancer survivorship, loss, grief and end-of-life comfort care, and self-care as patient care providers. All participants completed an end-of-course written evaluation. In July 2012, contact information was available for 48 participants, of whom 24 completed an internet survey. Results. All 67 participants successfully completed a digital story which they shared and discussed with course members. On the written post-course evaluation, all participants reported that combining digital storytelling with cancer education supported their learning and was a culturally respectful way to provide health messages. Additionally, 62 of 67 CHWs reported that the course increased their confidence to share cancer information with their communities. Up to 3 years post-course, all 24 CHW survey respondents reported they had shown their digital story. Of note, 23 of 24 CHWs also reported change in their own behavior as a result of the experience. Conclusions. All CHWs, regardless of computer skills, successfully created a digital story as part of the cancer education course. CHWs reported that digital stories enhanced their learning and were a culturally respectful way to share cancer-related information. Digital storytelling gave the power of the media into the hands of CHWs to increase their cancer knowledge, facilitate patient and community cancer conversations, and promote cancer awareness and wellness. Keywords: digital storytelling; Alaska Native; cancer education; Community Health Workers; health communications

Digital stories come from our community the voices and faces of our own people so it’s more powerful, has more of an impact. It touches people’s hearts. Community Health Worker cancer education course participant.

Alaska Native people have a rich heritage of sharing knowledge and wisdom through stories. Stories have been used for generations to pass on traditions, life lessons and cultural values. Community Health Workers (CHWs) in Alaska have identified that stories create pathways for connecting people, facilitating knowledge and under-

standing, enhancing remembering, engendering creativity, expanding perspectives, envisioning the future and inspiring possibilities (1). Digital storytelling combines oral storytelling traditions with computer technology. Since its inception in the early 1990s, digital storytelling has gained momentum as an education social advocacy tool (2). Paulo Freire, a Brazilian education theorist and social advocate, emphasized the importance of including learners’ thought and speech as the basis for developing critical understanding of personal experience, unequal conditions in society, and

Cancer education and digital storytelling highlights were presented at the annual Alaska Community Health Aide/Practitioner Conference, the Adult Education Research Conference (2011), and at the International Congress on Circumpolar Health (2012).

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knowledge (3). Based on Freire’s theoretical framework of empowerment (4), digital storytelling combines a person’s recorded voice with their choice of pictures and music to bring the power of the media into the voices and hands of community members (5) as a meaningful and culturally relevant health messaging tool. Alaska is the largest state in the US, comprising onefifth of the landmass of the contiguous 48 states. Alaska Native and American Indian people represent approximately 15% of the state population, with approximately 60% of Alaska Native people living in rural communities (6). There are 178 communities separated from regional hospitals by vast stretches of tundra, water, glaciers, and mountains. Geographic remoteness significantly affects the ability of many Alaska Native people to access the full spectrum of cancer care: education, prevention services, early detection, diagnosis, treatment, support services, palliative, and end-of-life care. Because Alaska rural communities are small, ranging in size from 20 to 1,200 people, even a single cancer diagnosis can have a huge impact on a community. Cancer was considered a rare disease among Alaska Native people as recently as the 1950s, but became the leading cause of mortality in the 1990s and remains so today (7). Contributing to cancer prevalence are modifiable risk factors experienced by many Alaska Native adults. Based on Alaska Behavioral Risk Factor Surveillance System data, as of 2009 37% of Alaska Native adults were current smokers, 26% reported no physical activity during the past month, 73% reported being overweight or obese, and 86% reported consuming less than 5 servings of fruits and vegetables per day (8). Alaska has a unique network of village-based health care providers. CHWs, including approximately 600 Community Health Aides/Practitioners (CHA/Ps) (9) and 120 Behavioural Health Aides (BHAs), are community members chosen by their tribes to provide community health care. CHA/Ps and BHAs have requested cancer information to supplement their basic medical training. Equipped with culturally appropriate cancer education and resources, they are in an ideal position to support community members to modify behavioral risk factors, and advocate and refer individuals for recommended screening exams. The purpose of this project was to learn how CHWs in Alaska perceived digital storytelling as a component of a cancer education curriculum and as a culturally respectful tool for sharing cancer-related health messages.

Methods An on-going dialogue with ‘‘Path to Understanding Cancer’’ course participants through a pre-course written application, end-of-course written evaluation, and internet survey informed this project. Cancer education participants were emailed throughout this dynamic process to

celebrate their contributions and to learn their experience with combining digital storytelling and cancer education.

‘‘Path to Understanding Cancer’’ course description The 5-day cancer education course was developed with and for Alaska’s CHWs in 1999 to provide basic cancer information and is continually updated to include medically- accurate information and to respond to CHWs’ expressed needs (10). In 2009, the cancer education course was expanded to include digital storytelling which combines computer-based technology with storytelling. Stories are told using both oral and visual dimensions. Participants synthesize and integrate their cancer understandings with a personal narrative to create their own culturally relevant cancer health message. Cancer education course curriculum includes facts about cancer among Alaska Native people, self-care, healthy lifestyle choices to decrease cancer risk or prevent cancer, recommended screening exams to prevent cancer or find changes early that may be cancer, cancer diagnosis and treatment, pain assessment and management, and loss, grief and end-of-life comfort care. The course manual, Understanding Cancer, written in collaboration with medical providers in Alaska and CHWs, includes 9 sections: (a) Self-care; (b) Wellness ways to prevent and decrease cancer risk; (c) Cancer and our genes; (d) Understanding cancer basics; (e) Cancer treatments: what to expect; (f) Cancer pain: assessment and management; (g) Loss, grief, and end-of-life comfort care; (h) Resources and (i) Community activities (11). Course faculty included a Registered Nurse with over 14 years of experience working in cancer education with Alaska Native people and an Alaska Native cancer survivor with digital storytelling expertise. Guest instructors, including a genetics counsellor and an oncology nurse, provided supplementary curriculum content. Additionally, tours of mammography and colorectal screening clinics were conducted. Participants Courses were advertised through existing CHW networks which included state-wide list serves, newsletters, previous course participants, and CHW program leadership. Ten CHWs were selected for each course based upon the support of their regional health corporation, their interest in learning about cancer, and their ability to attend the entire course. As part of the pre-course written application, CHWs described the ways cancer had affected their lives and how they hoped to apply their knowledge as a result of course participation. As expressed by course participants on the pre-course application: I think some people shy away from people affected by cancer, being they are not sure how to act around them. I for one would like to be there for the people and their family affected by this disease.


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Being as busy as we are in the clinic, we don’t do much on patient education regarding prevention of illness; we mostly focus on patient education on how to treat illness. I think this will help encourage me to talk to our patients more on prevention.

End-of-course written evaluation Upon completion of the cancer education course, participants were asked to complete a 3-page, written endof-course evaluation, which included check-box and open-ended questions, to share their experiences with combining digital storytelling and cancer education. Questions specific to digital storytelling were added to the evaluation tool that had been successfully used in the course evaluations previously conducted by the project team, prior to inclusion of digital storytelling. Internet survey methods To learn CHWs’ experience of digital storytelling over time, an internet survey was developed and implemented. The digital storytelling/cancer education course instructors developed the survey, with input from evaluation experts Regina Kuhnley and Dr. Mark Dignan. Questions were piloted with people available at the Anchorage Community Health Aide Program training centre, including CHAP instructors, CHA/Ps not involved with the course, and administrative support staff. The pilot survey reviewers checked for question readability and recommendations about the question wording to elicit the information we wanted to learn. The 10-question survey included check-box and open-ended questions. Contact information was available for 48 of 67 course participants at the time of internet follow-up, which ranged from 3 months to 3 years post-course participation. Participants for the post-course internet survey were recruited via an email introduction that included a link to survey monkey and an attached paper survey. Three email reminders were sent over the course of 1 month to prompt survey completion. Two gift certificates of $50 each were given as a thank you to 2 randomly selected participants for taking the time to provide their ideas by completing the survey. Names were drawn from the list of respondents who chose to provide their name and contact information to be entered into the drawing. No data were linked to participants’ names or contact information. All responses are reported anonymously.

Results Between May 2009 and May 2012, seven 5-day cancer education courses were provided for 67 CHWs (62 women and 5 men) from throughout Alaska. The majority of Alaska CHWs are women. Participants included 38 Alaska Native people, including Athabascan, Aleut, Tlingit, Yupik, and Inupiaq Alaska Natives, as well as 8 American Indian people, including Sioux, Cherokee, Blackfeet, and Pawnee individuals. Thirteen participants were Caucasian, 2 Asian, and 1 Hispanic. Ages of parti-

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cipants ranged as follows: 10 (1929 years old), 14 (30 39), 15 (4049), 15 (5059), and 12 (60 or older). As part of cancer education course participation, all 67 CHWs were successful in creating a cancer-related digital story regardless of prior computer experience. Participants chose to tell personal stories with cancer messages related to tobacco cessation, the importance of recommended cancer screening exams, cancer survivorship, loss, grief and end-of-life comfort care, and self-care as patient care providers. Additionally, participants described cultural perspectives about cancer, reflecting traditional values, languages, traditions, ways of knowing, intergenerational knowledge transmission, and other cultural attributes. Through sharing their story, participants hoped that it would encourage other people to tell their story as a way to end the silence that often surrounds the challenging topic of cancer. After completing their digital story, each participant responded in writing to the following statements: ‘‘I told this story because . . .’’ and ‘‘After watching my story, something I hope you think about . . .’’ In the words of a CHW: I’ve seen too many people die of cancer. I believe in early screening. I know it won’t detect all cancers or prevent all cancer deaths but it will decrease some. After watching my story, I hope people think about being screened. Think about the people that love you, who will be the one caring for you. Cancer affects everybody not just the person who has it.

End-of-course written evaluations All 67 course participants completed an anonymous endof-course written evaluation. All participants recommended the cancer education course and affirmed ways that combining digital storytelling with cancer education worked for them, supported their learning and was culturally respectful. By creating a personal digital story, participants integrated their cancer knowledge with their personal experience to critically reflect upon the health message they wanted to share within their network of relationships. Consequently, participants described how story creation increased their cancer knowledge by requiring them to evaluate, synthesize, and apply their cancer knowledge into a digital story. Course participants wrote how they came to the course not knowing much about cancer and left the week knowing lots of information and with a tool to provide cancer information back home. CHWs wrote detailed information, describing the ways digital storytelling supported their learning which included the following: By telling our own story it encouraged us to think about the subject, helped us to learn and speak out more.



My retention of information was greater than normal. I know how to talk about cancer a lot easier. It makes it easier when you know the facts and how important it is to get screened and keep up with them. I’ll be checking on the people back home.

CHW course participants enthusiastically expressed how combining digital storytelling with cancer education was culturally respectful. Storytelling was described as a way to share information that encouraged openness, tolerance, and sensitivity. Participants related how storytelling made it easier to hear the message by touching people’s hearts. As a result of cancer education course participation, 84% of participants (56 of 67) described ways they felt differently about cancer. Five people reported not feeling differently, 1 person was unsure and wrote that ‘‘the pain is still there but maybe lessens it some’’, 2 responses were not specific to the question and 3 evaluations were blank. Some of the views expressed were as follows: Less fear of the unknown. It’s not as scary. It’s okay to say ‘Cancer’. Can talk about it now and say the word cancer. Feel more comfortable talking and learning. It’s okay to cry okay to laugh. I can be more open. It is alright to grieve, share, and let go. It felt good to get that heavy thing I’ve been carrying out. It was a way for me to share my grief. It’s [Cancer] not a death sentence; it’s not something we should hide from.

In response to the question, ‘‘By creating your own digital story do you feel more confident to share cancer education with people in your community?’’, overall 93% (62 of 67) responded affirmatively. Representative CHW quotes are: I have more information to share plus I have the courage how to be there for someone and their family with cancer. More aware of survivors’ and caregivers’ feelings. I learned a lot and will be much more aware of family, friends, and self-getting screenings and pay attention to their results. Also will offer to go with others. I am the type not to speak in front of a crowd, so doing this helps a lot. Now I know what to say. I have a better knowledge of cancer. I have a tool to introduce the topic.

In response to the open-ended question, ‘‘Will you do anything differently as a result of cancer education for you, your family, and in your work?’’, participants wrote detailed information describing intent to support healthy

behaviors for themselves, their families and patients. Very few evaluations were left blank. 85% of participants (57 of 67) identified wellness changes they planned to make as a result of course participation for themselves, including having recommended screening exams (16 participants), eating healthier (10 participants) and being more physically active (7 participants). Additionally, 81% of participants (54 of 67) described ways they planned to support family health, including encouraging family screening activities (20 participants) and healthier eating (5 participants). As reported by 85% of CHW participants (57 of 67), the course strengthened their patient care practices, which included talking about cancerrelated risk reduction behaviors and encouraging their patients to have recommended screening exams. They reported feeling more confident in their cancer knowledge and communication skills as well as being empowered to provide cancer education and support community wellness to decrease cancer risk. In the words of CHWs: I learned to explain cancer to patients instead of the clinical gobbledygook, where you lose them in 2 minutes. Speak out. Make sure to help people get their screening. Encourage screening.

Internet survey results Out of 67 course participants from the cancer education/ digital storytelling courses offered May 2009May 2012, 19 people were lost to follow-up, including 1 person who died from brain cancer. Of the remaining 48 course participants, 24 people completed the survey: 19 via survey monkey and 5 via emailed paper survey. Survey respondents included 22 females and 18 individuals who self-identified as Alaska Native. Up to 3 years post-course, all 24 CHW survey respondents reported that they had shown their digital story to a variety of individuals. CHWs related they had shown their stories as part of community presentations, family gatherings, health fairs, school presentations, and clinic visits. Viewers included youth, elders, patients, community members, family, friends, co-workers, and tribal councils. Additionally, people had posted their stories on YouTube, Facebook pages, and other web sites. More recently, CHWs have posted their stories on the cancer education resource page of the akchap.org website. All survey respondents described digital storytelling as being a culturally respectful and effective health messaging tool as reflected in the following quote. I think it is a beautiful way to get cancer health messages out to people because they can hear your voice, see your photos, and words. This is different than reading an article in the paper or hearing an ad on the radio. It’s not some abstract or unknown entity sharing information it’s real people, people like you and me, maybe people that you know


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personally. It gives a face to the message and not just empty words.

Furthermore, 23 of 24 CHWs reported personal behavior change as a result of the experience, including having recommended screening exams (10 people), quitting tobacco (1 person), decreasing tobacco use (1 person), increasing physical activity (10 people), and eating healthier (12 people). In the words of a CHW: The whole experience of cancer education and digital storytelling was very uplifting and it made me more aware of how cancer affected me in my decisions for myself and how I want to convey my message to my family about how they feel about it. I was given a tool in order to reach out to my closest family in a way that I wasn’t able to before. I tried to talk about screening a few times but this is a way to open the topic without being confrontational. I’m showing them why I want this for them because I love them and care about their health. Digital storytelling is a very powerful medium for getting these messages across the barriers of other forms of communication.

The transformation of personal experiences into the physical reality of a digital story also allowed participants to objectively view their own experiences, opening a pathway for group discussions, course material and personal reflections to create new meaning from past experiences (13,14). Participants expressed feelings of healing and renewal as a result of developing, discussing and showing their stories. The creation of digital stories leading to new reflections and behaviors highlights the use of digital storytelling as a powerful health messaging tool. Digital storytelling bridges historical cultural traditions of storytelling with technology to create new traditions for passing on knowledge to future generations. In the words of course participants: We live in such a technology based world that digital storytelling naturally fits as a way to effectively tell our story. Digital stories have a personal perspective that people understand. Our stories come from the heart. Community members lend their natural storytelling abilities to help educate others.

Discussion

Conclusions

The creation of digital stories was an integral part of a 5-day cancer education course for CHWs in Alaska. Digital storytelling weaves past storytelling traditions with new technologies, carrying people’s stories across time past, present and future. CHWs took their digital stories home as tools to share their heartfelt cancerrelated health messages with people in their communities. These stories connect knowledge with emotion, linking realms of wisdom. As Wilson (12) advocates in Research Is Ceremony, indigenous methodologies ask that theses realms of wisdom be connected:

Evaluation data from this project revealed that combining digital storytelling with cancer education for CHWs in Alaska feasibly enhanced learning in a culturally respectful way. Digital stories offered a forum for individual narratives to be expressed in both oral and visual dimensions, sharing the experience and culture of each participant. Participants in the cancer education courses expressed enthusiasm over learning how to use computer-based technology to create and tell a personal story, emphasizing the accessibility of digital storytelling to even those with minimal technological experience. Creating and telling of personal stories by course participants enhanced understanding of cancer, confidence with discussing cancer, and provided a tool to assist CHWs to share cancer-related health messages in their clinics and communities. This project plants the seeds for future cultivation and exploration of the transformative power of digital storytelling. Qualitative methods will yield a deeper understanding of CHWs’ experience of creating a personal cancer-related digital story and how that influences health choices. Additionally, it is important to gain insight into how story creators continue to disseminate their digital stories and share them within their networks and communities. Much is to be learned about how digital story viewing affects cancer perceptions and health behaviors. Also yet to be fully explored are the elements of digital stories that make them a powerful tool for health messaging. Digital storytelling holds promise as an innovative and culturally respectful tool for health communication.

the western tradition teaches us to separate our head from our heart and our spirit. Therefore those roads and those lines of communications aren’t linked up as they should be, and our cultures and our traditions teach us to hook those lines of communication up.

Stories can be understood as both a reflection of culture and the creation of behavior change (13). Course participants’ construction of digital stories influenced their post-course behavior, with self-reported changes that improved participants’ health, nurtured healthy activities for their families, and strengthened the ways they provided patient care. Paulo Freire discussed and implemented a model of empowerment in which people told and retold personal stories to transform behaviors (4). In a similar fashion, participants told and retold their own stories through the creation and discussion of digital stories, culminating in a final product that prompted many to alter their behavior to reflect healthier choices.

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Acknowledgements Thank you to Community Health Workers in Alaska who participated in the ‘‘Path to Understanding Cancer’’ course and created their heartfelt digital story to share a meaningful cancer-related message. This project was supported in part by the American Cancer Society (‘‘Developing Arts-Based Cancer Education with Alaska Native People’’ 117126-MRSGT-09-007-01-CPPB) and the Centers for Disease Control. This manuscript was approved by the Alaska Native Tribal Health Consortium (ANTHC) Health Research Review Committee (HRRC) on behalf of the ANTHC Board of Directors.

Conflict of interest and funding All authors confirm that they have no financial and personal relationships with other people or organizations that could potentially influence the results or interpretation of the information presented within this manuscript.

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References 1. Cueva M, Kuhnley R, Lanier A, Dignan M. Story: the heartbeat of learning. Convergence. 2007;39:818. 2. Lambert J. Digital storytelling capturing lives, creating community. Berkeley, CA: Digital Diner Press; 2009. 1 p. 3. Shor I. Empowering education. Chicago, IL: Chicago University Press; 1992. p. 312. 4. Freire P. Pedagogy of the oppressed. New York: Continuum; 2003. 5. Cueva M. Alaska Native Tribal Health System Community Health Aide Program. Cancer education for Alaska Native people: the power of digital storytelling. Health Educ Behav. 2010;37:61920. 6. U.S. Census Bureau. State and county quick facts. Data derived from Population Estimates, Census of Population and Housing. Washington, DC: U.S. Census Bureau; 2011. 7. Lanier AP, Kelly JJ, Maxwell J, McEvoy T, Homan C. Cancer in Alaska Natives 19692003, 35-year report. Anchorage, AK: Alaska Native Tribal Health Consortium Office of Alaska

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Native Health Research and Alaska Native Epidemiology Center; 2006. 1 p. Alaska Department of Health and Social Services, Division of Public Health. Health risks in Alaska among adults: Alaska Behavioral Risk Factor Survey 2009 Annual Report. Juneau, AK: Alaska Department of Health and Social Services, Division of Public Health; 2011 [cited 2012 Nov 14] Available from: http://dhss.alaska.gov/dph/Chronic/Documents/brfss/pubs/ BRFSS09_FullReport.pdf Golnick C, Asay E, Provost E, Van Liere D, Bosshart C, Rounds-Riley J, et al. Innovative primary care delivery in rural Alaska: a review of patient encounters seen by community health aides. Int J Circumpolar Health. 2012;71:18543. Kuhnley R, Cueva M. Learning about cancer has brightened my light. Cancer education for Alaska Community Health Aides and Community Health Practitioners (CHA/Ps). J Canc Educ. 2011;26:5229. Cueva M, Kuhnley R, Stueckemann C, Lanier A, McMahon P. Understanding cancer. Anchorage: Alaska Native Tribal Health Consortium; 2010 [cited 2012 Nov 14] Available from: http://www.akchap.org/html/resources/cancer-education/ understanding-cancer.html Wilson S. Research is ceremony: indigenous research methods. Halifax: Fernwood; 2008. 17, 119 pp. Burgess J. Hearing ordinary voices: cultural studies, vernacular creativity and digital storytelling. J Media Cult Stud. 2006; 20:20114. Gubrium G. Digital storytelling: an emergent method for health promotion research and practice. Health Promot Pract. 2009;10:18691.

*Melany Cueva Community Health Aide Program Alaska Native Tribal Health Consortium 4000 Ambassador Dr Anchorage, AK 99508 USA Tel: (907) 729-2441 Email: [email protected]


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Experience with cochlear implants in Greenlanders with profound hearing loss living in Greenland Preben Homøe1*, Ture Andersen2, Aksel Grøntved3, Lone Percy-Smith1 and Michael Bille1 1

Department of Otolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; 2Department of Audiology, Odense University Hospital, Odense, Denmark; 3Department of Otolaryngology, Head and Neck Surgery, Odense University Hospital, Odense, Denmark

Objective. Cochlear implant (CI) treatment was introduced to the world in the 1980s and has become a routine treatment for congenital or acquired severe-to-profound hearing loss. CI treatment requires access to a highly skilled team of ear, nose and throat specialists, audiologists and speech-language pathologists for evaluation, surgery and rehabilitation. In particular, children treated with CI are in need of long-term postoperative auditory training and other follow-up support. Design. The study is retrospective with updated information on present performance. Results. Since 2001, a total of 11 Greenlandic patients living in Greenland have been treated with CI, 7 children and 4 adults. Of these children, 4 use oral communication only and are full-time CI-users, 2 with fulltime use of CI are still in progress with use of oral communication, and 1 has not acquired oral language yet, but has started auditory and speech training. Six children attend mainstream public school while one child is in kindergarten. Of the adults, only 1 has achieved good speech perception with full-time use of CI while 3 do not use the CI. Discussion. From an epidemiological point of view, approximately 13 children below 6 years are in need of a CI every second year in Greenland often due to sequelae from meningitis, which may cause postinfectious deafness. Screening of new-borns for hearing has been started in Greenland establishing the basis for early diagnosis of congenital hearing impairment and subsequent intervention. The logistics and lack of availability of speech therapists in Greenland hampers possibilities for optimal language and speech therapy of CI patients in Greenland. This study aims at describing the results of CI treatment in Greenlanders and the outcome of the CI operations along with the auditory and speech/language outcomes. Finally, we present a suggestion for the future CI treatment and recommendations for an increased effort in the treatment and rehabilitation of implanted patients in Greenland. Keywords: cochlear implant; hearing, deafness; Inuit; Greenland

ersons with a profound hearing impairment, either congenital or acquired or pre- or post-lingual, in the remote Arctic areas are often left alone without much rehabilitation or support from the authorities. In Greenland, there used to be a school for the deaf but it has since been closed down. Since introduction in the 1980s, cochlear implantation (CI) has become a routine treatment option in patients with a severe-to-profound hearing impairment and limited benefit from conventional hearing aids. A CI consists of an electrode array implanted in the cochlea and connected to a receiver placed under the skin. The external microphone and sound processor transmit signals to the internal device

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providing electrical stimulation to the auditory nerve that is conveyed to the brain and perceived as sound. Thus, it has become possible to restore speech comprehension ability in postlingually deafened patients. Children with a congenital severe-to-profound hearing impairment are, with the use of CI, able to develop speech perception and spoken language skills comparable to normal hearing children when implanted early, preferably before 12 months of age (1,2). It has been shown that quality of life after CI can be improved substantially (3). Also, CI has been shown to be cost-effective in industrialised countries but with varying results between studies (4). Cost-effectiveness of CI in Greenland or


Experience with cochlear implants in Greenlanders

remote areas has not been examined. A candidate for CI in Greenland is sent to Denmark for evaluation and surgery. Post-operative rehabilitation is supposed to take place in Greenland with some guidance from the speech language pathologist from the CI centre. We have examined the performance and status of the implanted Greenlandic patients who live in Greenland. The study is retrospective and covers the period between 2001 and 2011. The medical records have been scrutinised, and the districts where the patients live have been contacted for information on language, school attendance and the use of the CI.

Results The first Greenlandic patient received a CI in 2001. During the 9 years, 7 children aged between 2 and 5 years and 4 adults aged between 42 and 50 years have had CI done. The gender distribution for the children was 3 girls and 4 boys and for the adults, 2 females and 2 males. Of the children, 2 had hearing impairment due to pneumococcal meningitis, 4 had non-specified congenital hearing loss and 1 was congenitally deaf due to genetically verified Connexin 26 related hearing impairment, 35delG mutation (GJB2). Of the adults, 3 were profoundly hearing impaired due to pneumococcal meningitis and 1 was impaired after treatment with aminoglycoside. Six of the 7 children were implanted bilaterally, 2 simultaneous and 4 sequential, while 3 of the 4 adults were implanted unilaterally. Nine patients were implanted with Nucleus CI24RE CA electrodes and 2 adult patients were implanted with split-electrodes due to ossification of the cochlea after pneumococcal meningitis. The 2 patients (aged 49 and 50 years) with cochlear ossification were implanted 4 months and 3.5 years after the meningitis episode, respectively, while the one (46 years-old) without ossification was implanted 5 months after the meningitis episode. The 2 children (aged 27 and 39 months) with hearing loss after pneumococcal meningitis were implanted 1.6 and 2.1 years after the infection, respectively. The median age of identification for the five congenitally hearing impaired children was 1.5 years (range 0.83.7) and the median age of implantation was 2.9 years (range 2.15.7 years). Four patients live in Nuuk, 3 in Tasiilaq, 1 in Ilulissat, 1 in Sisimiut, 1 in Nanortalik and 1 in Kangaatsiaq. Two patients experienced a post-operative infection and were treated with antibiotics. However, one of these patients needed the CI to be removed and a later reimplantation to control the infection. One patient suffered from post-implantation facial nerve stimulation and needed switch-off of the offending electrodes. Contact to the local districts in Greenland and one of the two speech language therapists in Greenland revealed that 4 children use oral communication mode and are full-time CI-users, 2 are full-time users of CI and

are still in progress using oral communication and 1 has not developed spoken language as yet but has started auditory and speech training. One of the children is also psychomotorically retarded. Six children attend mainstream public school while 1 is in mainstream kindergarten. Of the adults, only 1 (deafened after exposure to gentamycin) has developed speech comprehension with full-time use of CI. The other 3 adults who were deafened after meningitis and who have additional alcohol problems do not use the CI and are left with lip-reading.

Discussion It is expected that between 1 and 3 children are either born deaf or become deaf or attain profound hearing loss mainly after meningitis in Greenland every year. Most deafness in Greenland relates to infections such as meningitis, which is potentially preventable. CI is one of the major breakthroughs in the world of medicine. The technology offers the possibility to establish or reestablish hearing in otherwise totally deaf or profoundly hearing impaired persons. In the case of a severeto-profound hearing impairment with only limited benefit of conventional hearing aids, CI enables speech comprehension and spoken language communication (5). Early identification and intervention with the fitting of hearing aids before 6 month of age is important for children with a congenital or early-acquired hearing impairment in order to achieve optimal results in terms of spoken language and speech development (6). When CI is needed, implantation is preferred before children reach 12 months of age (2). This study demonstrates delayed identification of children with severe or profound congenital hearing impairment typical for a population without a neonatal hearing-screening programme (7). However, a significant delay from identification to effective treatment is also shown. Universal hearing screening in new-borns was introduced in Greenland in 2007 as a 2-stage screening test with transient evoked otoacoustic emissions. In case of failure of the screening procedure, the new-born is referred for further examination and audiological testing by a visiting audiological physician at the local hospital or in the ear, nose and throat department at the main hospital in Nuuk. Establishing neonatal hearing screening is essential for early detection and intervention but emphasis must still be placed on immediate audiological evaluation when screening is not passed and timely referral for specialised evaluation in Denmark whenever needed. Timely identification of post-meningitis bilateral severe-to-profound hearing loss and prompt referral for definitive audiological evaluation and appropriate treatment with CI is required due to the risk of intracochlear fibrosis or ossification precluding proper electrode insertion (8). This study shows a significant delay for all the post-meningitis patients leading to suboptimal electrode


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insertion in 2 cases. Therefore, physicians in Greenland should show alertness of hearing loss after meningitis cases, and all meningitis patients in Greenland should have performed a hearing test as soon as possible after the incident. If there is any suspicion of profound hearing loss, the patient should be discussed immediately with the audiological specialists in Denmark. A problem in Greenland is the limited access to auditory and verbal training as there are only 2 trained speech therapists in Greenland to take care of the entire population of 56,000, including speech-related problems in school children. Also, education and support to the parents of implanted children are crucial to achieve the most optimal speech and language results (1). In Greenland, the important post-operative follow-up and treatment is in need of further attention in order to increase the outcome of treatment with CI. A rehabilitation programme would enhance this, and it is suggested that this be developed as soon as possible. This could be done by including the group of dedicated health care workers involved in this field, such as physicians in audiology, speech therapists, otosurgeons, the local district physicians and the social and child care authorities in the local districts. A programme could involve the use of the Internet such as Skype or other telemedicine facilities, which are already established and working in Greenland. A yearly follow-up by Danish specialists may be suggested in order to attend to potential problems as early as possible. Language barrier may also be an obstacle. It is therefore important that Greenland has enough updated speech therapists who can speak the Greenlandic language. This is increasingly important as the school for the deaf has been closed in Greenland. Other existing handicaps or disabilities in some of the affected patients or social deprivation could also interfere with the outcome of cochlear implantation. An important aspect of success after CI is the cooperation and attitude of the patients and their families. The selection of the patients is therefore of major clinical significance and should be performed meticulously. This has now resulted in a decision by the authorities in Greenland not to continue with CI in adults but only offer this treatment to children.

Conclusions CI treatment is difficult to perform optimally in Greenland. CI treatment of severe or profoundly hearing impaired Greenlandic children can be performed successfully. Earlier intervention in both congenital and acquired profound hearing loss is needed. Skype or telemedicine could be a valuable tool in the rehabilitation process.

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Language barrier and social problems are obstacles. There is a need for systematic auditory and verbal rehabilitation. A yearly control and follow-up by a CI specialised speech-language pathologist is suggested. A program for rehabilitation of all Greenlandic CI patients is urgently needed.

Acknowledgements Thanks to the speech therapists in Nuuk, Greenland, for providing important information.

Conflict of interest and funding No one has benefitted economically from this study and no one has a conflict of interest to declare.

References 1. Percy-Smith L, Busch GW, Sandahl M, Nissen L, Josvassen JL, Bille M, et al. Significant regional differences in Denmark in outcome after cochlear implants in children. Dan Med J. 2012;59:A4435. 2. Dettmann SJ, Pinder D, Briggs RJ, Dowell RC, Leigh JR. Communication development in children who receive the cochlear implant younger than 12 months: risks versus benefits. Ear Hear. 2007;28:S118. 3. Wanscher JH, Faber CE, Grøntved AM. Cochlear implantation in deaf adults. Effect on quality of life. Dan Med J. 2006; 168:26569. 4. Lammers MJ, Grolman W, Smulders YE, Rovers MM. The cost-utility of bilateral cochlear implantation: a systematic review. Laryngoscope. 2011;121:26049. 5. Svirsky M, Teoh S, Neuburger H. Development of language and speech perception in congenitally, profoundly deaf children as a function of age at cochlear implantation. Audiol Neurootol. 2004;9:22433. 6. Moeller MP. Early intervention and language development in children who are deaf and hard of hearing. Paediatrics. 2000; 106:e43. 7. Fortnum H, Davis A. Epidemiology of permanent childhood hearing impairment in Trent region, 1985-1993. Br J Audiol. 1997;31:40946. 8. Philippon D, Bergeron F, Ferron P, Bussie`res R. Cochlear implantation in postmeningitic deafness. Otol Neurotol. 2010; 31:837. *Preben Homøe Department of Otolaryngology Head and Neck Surgery and Audiology Rigshospitalet, University Hospital of Copenhagen Blegdamsvej 9 DK-2100 Ø Denmark Tel: 45 35452774 Fax: 45 35452690 Email: [email protected]


CHRONIC DISEASE æ

Raised BMI cut-off for overweight in Greenland Inuit a review Stig Andersen1,2,3*, Karsten Fleischer Rex1,2, Paneeraq Noahsen1, Hans Christian Florian Sørensen4, Gert Mulvad5 and Peter Laurberg6 1

Arctic Health Research Centre, Aalborg University Hospital, Aalborg, Denmark; 2Department of Medicine, Queen Ingrids Hospital, Nuuk, Greenland; 3Department of Geriatric Medicine, Aalborg University Hospital, Aalborg, Denmark; 4Ammassalik Hospital, Ammassalik, Greenland; 5Primary Health Care Clinic, Nuuk, Greenland; 6Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark

Background. Obesity is associated with increased morbidity and premature death. Obesity rates have increased worldwide and the WHO recommends monitoring. A steep rise in body mass index (BMI), a measure of adiposity, was detected in Greenland from 1963 to 1998. Interestingly, the BMI starting point was in the overweight range. This is not conceivable in a disease-free, physically active, pre-western hunter population. Objective. This led us to reconsider the cut-off point for overweight among Inuit in Greenland. Design and findings. We found 3 different approaches to defining the cut-off point of high BMI in Inuit. First, the contribution to the height by the torso compared to the legs is relatively high. This causes relatively more kilograms per centimetre of height that increases the BMI by approximately 10% compared to Caucasian whites. Second, defining the cut-off by the upper 90-percentile of BMI from height and weight in healthy young Inuit surveyed in 1963 estimated the cut-off point to be around 10% higher compared to Caucasians. Third, if similar LDL-cholesterol and triglycerides are assumed for a certain BMI in Caucasians, the corresponding BMI in Inuit in both Greenland and Canada is around 10% higher. However, genetic admixture of Greenland Inuit and Caucasian Danes will influence this difference and hamper a clear distinction with time. Conclusion. Defining overweight according to the WHO cut-off of a BMI above 25 kg/m2 in Greenland Inuit may overestimate the number of individuals with elevated BMI. Keywords: BMI; cut-off point; overweight; obesity; Greenland Inuit; ethnicity; review

he on-going epidemic of obesity is associated with complications such as psychosocial disease states, muscle and joint disorders, diabetes, increased cancer risk, cardiovascular disease, and all-cause mortality (15). Thus, obesity is a major threat that may slow or even reverse the gains in life expectancy that have been achieved over the past decades. It is important to identify people at risk both at the individual level in everyday clinical practice and at a population level to identify a population hazard and guide preventative measures. The guidelines issued by the WHO have defined overweight and obesity as a body mass index (BMI) of 25 kg/m2 or higher and 30 kg/m2 or higher, respectively (2). These cut-off points are derived from morbidity and mortality data from predominantly Caucasian populations in Europe and the US (2,6). However, ethnic differences in body build may exist (7) that may render

T

cut-off points inappropriate (8). Thus, the mean population level of BMI is lower in Asian than in European and US populations while the prevalence of type-2 diabetes is high (8,9). Also, a high level of mean population BMI has been found in pre-western Greenland Inuit (10) that has been associated with a low occurrence of type-2 diabetes (11). Such data on ethnic differences have added to the questioning of whether the WHO defined cut-off points can be generalised to non-Caucasian populations (6,1214).

Body build and BMI in Inuit Inuit body build differs from that of Caucasians in that Inuit have larger torsos and shorter limbs (15,16). This increases BMI independent of the degree of body fat as the torso carries more weight per centimetre than legs (17), and 31% of young, fit hunters in Greenland investigated around 1963 were classified as overweight


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this among Greenland Inuit requires access to height, weight, physical examination, and data on the occurrence of disease in pre-western Inuit. A comprehensive population-based study of Greenland Inuit was performed in 19621964, prior to the westernisation of Greenlandic societies (11). The original data sheets from East Greenland were kept and donated to Queen Ingrids Hospital in Nuuk, Greenland, by the descendants of the late Jørgen Littauer. The data covered 96.9% of the population of East Greenland (n 1,852) and included height, weight, medical history and a physical examination (21). Andersen and colleagues calculated BMI for evaluation of overweight and obesity (10). They found that BMI in healthy 2029 year old men displayed a symmetrical distribution that is unique for biological data (Fig. 1) (10). According to the WHO definition, 31% of the young hunters were rendered overweight. This is not likely considering that the Inuit hunters around 1963 lived a physically very active life that depended on hunting and fishing from kayaks in the Arctic sea where excess body fat would be a hazardous drawback. Also, excessive food intake was limited to short periods that were regularly followed by periods of food shortages. Still, malnourishment was prevented by the distribution of food through trading posts during famine. Also, systematic illnesses were prevented as public health care was established in East Greenland in the late 1940s. Based on the symmetrical distribution, Andersen and colleagues calculated 90-percentile cut-off points for defining overweight in healthy Inuit men and women. These cut-off points were around 10% higher than those defined by the WHO (see Table I).

when using the WHO cut-off points (10). Two different approaches have been used to quantify the impact on BMI of this difference in body build as discussed below.

Sitting-height/height ratio Shorter legs relative to the torso increase the ratio of sitting height to standing height. This is calculated as the sitting height divided by total height, also known as the Cormic index (17). Inuit have a higher length of torso relative to the legs and hence a higher sitting-height/ height ratio compared to non-Inuit whites (16,18,19). This influences BMI towards higher values (17,20). Consequently, BMI may overestimate the prevalence of overweight and obesity in Inuit populations compared to other populations. This may be corrected for by identifying and using the BMI cut-off values in Inuit that detects the same degree of adiposity and risk profile as the BMI cut-off of 25 and 30 kg/m2 does in Caucasians. Charbonneau-Roberts et al. reported a sitting height/ height ratio of 0.54 for Inuit while it was 0.52 for non-Inuit (18). Norgan calculated the influence of sitting-height/ height ratio on BMI from anthropometric measurements on 18,000 individuals (17). By using his estimate of an increase of 0.8 kg/m2 for men and 1.2 kg/m2 for women for each 0.01 increment in sitting-height/height ratio, the BMI that corresponds to 25 kg/m2 in non-Inuit whites is around 10% higher in Inuit (see Table I). BMI distribution in pre-western Inuit A way to define an optimal BMI for a population is to identify a healthy population that is not malnourished and estimate a BMI norm from this population. To do

Table I. The BMI in Inuit that corresponds to a BMI of 25 kg/m2 in non-Inuit whites as estimated by different methods: Noahsen assessed Inuit BMI based on plasma lipids Population

Measure

BMI

Reference

Non-Inuit whites

Reference

25

WHO

(2)

Inuit men

HDL

27.62

Jørgensen, Noahsen

(22,31)

Triglycerides HDL

27.18 28.36

Jørgensen, Noahsen Young, Noahsen

(22,31) (23,31)

Triglycerides

26.36

Young, Noahsen

(23,31)

Distribution

27.9

Andersen

(10)

SH/H ratio

26.6

Chateau-Degat, Norgan

(15,17)

HDL

26.54

Jørgensen, Noahsen

(22,31)

Triglycerides

27.18

Jørgensen, Noahsen

(22,31)

HDL

27.93

Young, Noahsen

(23,31)

Triglycerides Distribution

27.27 27.7

Young, Noahsen Andersen

(23,31) (10)

SH/H ratio

27.4

Chateau-Degat, Norgan

(15,17)

Inuit women

Andersen assessed Inuit BMI based on BMI distributions. Norgan assessed BMI based on sitting height/height ratios (31). Noahsen computed cut-off points based on data extracted from comparative studies of BMI and plasma lipids (22,23).

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Cut-off for overweight in Inuit

Number of individuals (%)

70

are given in Table I. A clear pattern was seen with a BMI of around 10% higher in Inuit compared to non-Inuit for the same degree of dyslipidaemia. These levels are in accordance with the levels suggested from estimations of body build (Table I).

60 50 40 30

Discussion

20 10 0 16

18

20

22

24 BMI

26

28

30

32

Fig. 1. Distribution of BMI among 2029-year-old men in East Greenland in 1963 (n 176). The WHO definition of overweight renders 31% of young hunters overweight. Defining overweight by an Inuit 90-percentile sets the cut-off point at 27.9 kg/m2 in Inuit men (from ref. 10).

LDL-cholesterol, triglycerides and BMI The impact of BMI on plasma lipids differed between Inuit and non-Inuit in the 2 studies that included both Inuit and non-Inuit and thus allowed for a comparative analysis (22,23). This may be explained in 2 ways. The higher plasma lipids in Inuit could be a marker of environmental and genetic factors not related to overweight that contributed to a difference in the cardiovascular risk between Inuit and non-Inuit. This interpretation was supported by the lower occurrence of ischemic heart disease among pre-western Greenland Inuit compared to Caucasian populations (24,25). However, the occurrence of ischemic heart disease among Greenland Inuit has risen markedly (25,26) in parallel with the transition of societies in Greenland towards a more sedentary lifestyle and a change in dietary habits with a higher intake of imported foods (27,28). This towards a more This challenges the former explanation. A different interpretation is that it is not the lipids but rather the BMI that differs between Inuit and non-Inuit. This is in keeping with the high level of physical activity in pre-western Inuit that contributed to the low occurrence of ischemic heart disease in pre-western Inuit (29) and the subsequent rise in ischemic heart disease as the sedentary lifestyle gains ground (30). Based on the assumption that Inuit and non-Inuit tend to have similar levels of lipids and that the differences observed relate to overweight, it is possible to calculate the Inuit BMI that gives the same lipid profile as a BMI of 25 kg/m2 in non-Inuit. This was carried out by Noahsen (31). Data reported from Greenland by Jørgensen et al. (22) and from Canada by Young (23) were used to calculate regression equations for the association between BMI and HDL-cholesterol and triglycerides in Inuit and in non-Inuit (31). The Inuit BMI corresponding to the nonInuit BMI of 25 kg/m2 was calculated for both HDLcholesterol and triglycerides in men and women. Values

Three different approaches were used to evaluate the influence of Inuit ethnicity on BMI cut-off points. Independently they suggested that BMI cut-offs for overweight and obesity should be 10% higher in Inuit compared to non-Inuit whites. These uniform findings all point towards a higher BMI in Inuit for the same degree of risk of disease that is in keeping with the finding that the degree of metabolic disturbances is lower at the same BMI in Inuit compared with Caucasians (22,23,32). Only one anthropometric measure of adiposity was considered in this analysis. The prediction of disease risk can be done from a number of measures of excess body fat. Some are direct and some are indirect measures. Computer tomography and dual energy X-ray absorptiometry are direct measures of body fat but both are cumbersome and associated with exposure to radiation that increases the risk of cancer, mainly in the former as dual energy X-ray absorptiometry only causes limited radiation exposure. Still, these methods are not appropriate for everyday clinical practice or large-scale clinical studies. Bioelectrical impedance is another approach that has been used in a single study of Canadian Inuit (15). It requires equipment and is based on the assumption that the body is a cylindrical-shaped ionic conductor with non-adipose tissue as resistor and capacitor, which is influenced by tissue hydration (33) and ethnicity (34). Hence, caution should be taken when evaluating results and the method should be validated in Inuit. Also, these direct measures of the amount of body fat are not able to assess the metabolic effect of the fat detected. There are, for example, ethnic differences in the compartments of abdominal adipose tissue, visceral and subcutaneous abdominal adipose tissue (35) that may differ in metabolic effects (36). The distribution of these compartments did not differ between Inuit and non-Inuit whites (35) but may differ between superficial and deep subcutaneous adipose tissue (36). In addition, Inuit host metabolically active brown adipose tissue (37) that has a different metabolic effect compared to white adipose tissue (38). Still, there is an association between the amount of excess body fat and the risk of ischemic heart disease, as well as an association between excess body fat and anthropometric measures of adiposity (39,40). Anthropometric measures are simple and easy to obtain. They include BMI and waisthip-ratio that assess total body adiposity, while waist circumference describes central adiposity. They are all indirect measures of adiposity and have an inherited imprecision in identifying


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metabolic risk. Still, they have a predictive value for metabolic syndrome and vascular health (3,5,39,40). We chose to focus on BMI as a model for analysing the influence of ethnicity on anthropologic measures of adiposity. There is some agreement between the different anthropometric measures (41) but the data should not be extended to cover other measures of body fat. Nevertheless, they draw attention to the importance of ethnicity in the assessment of overweight and obesity among Inuit.

Conclusion A BMI cut-off point of 25 kg/m2 that defines overweight in non-Inuit corresponded to a BMI cut-off point of approximately 27.5 kg/m2 in Inuit as estimated using 3 independent approaches. The relatively higher BMI cutoff point among Inuit compared to non-Inuit and the lower impact of high BMI on metabolic indicators suggest the need for a higher BMI cut-off in Inuit for the same degree of disease risk. However, the association is complex. It is modified by the genetic admixture of Inuit and non-Inuit that over time may cause an underestimation of obesity rates if rigorous BMI cut-off points are used for all populations in Greenland. It may be useful to include the degree of Inuit heritage in the evaluation of metabolic risk when using BMI. None of the 3 approaches reviewed here can be used to settle ethno-specific BMI cut-off points and the association with different rates of diseases related to obesity remains to be determined in prospective studies with diseases as outcome variables.

Conflict of interest and funding This study was supported by grants from Greenland Government and Karen Elise Jensen Foundation.

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*Stig Andersen Arctic Health Research Centre Aalborg University Hospital Hobrovej 42D 9000 Aalborg Denmark Tel: 45 99321960 Fax: 45 99326108 Email: [email protected]


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Cystatin C and lactoferrin concentrations in biological fluids as possible prognostic factors in eye tumor development Mariya A. Dikovskaya1,2, Alexandr N. Trunov2,3, Valeriy V. Chernykh2 and Tatyana A. Korolenko1* 1

Institute of Physiology, Siberian Branch of Russian Academy of Medical Sciences, Novosibirsk, Russia; 2The S.N. Fyodorov Federal State Complex ‘‘Eye Microsurgery’’ (Novosibirsk Branch), Novosibirsk, Russia; 3Research Center of Clinical and Experimental Medicine of SB Branch

Objectives. To investigate the possible role of cystatin C in eye biological fluids locally and in serum and lactoferrin revealing anti-tumor activity in eye tumor development. Background. The increased number of eye tumors was registered recently not only in the countries with high insolation, but also in the northern countries including Russia (11 cases per million of population). Search for new biological markers is important for diagnosis and prognosis in eye tumors. Cystatin C, an endogenous inhibitor of cysteine proteases, plays an important protective role in several tumors. Lactoferrin was shown to express anti-tumor and antiviral activities. It was hypothesized that cystatin C and lactoferrin could serve as possible biomarkers in the diagnosis of malignant and benign eye tumors. Study design. A total of 54 patients with choroidal melanoma and benign eye tumors were examined (part of them undergoing surgical treatment). Serum, tear fluid and intraocular fluid samples obtained from the anterior chamber of eyes in patients with choroidal melanoma were studied. Methods. Cystatin C concentration in serum and eye biological fluids was measured by commercial ELISA kits for human (BioVendor, Czechia); lactoferrin concentration by Lactoferrin-strip D 4106 ELISA test systems (Vector-BEST, Novosibirsk Region, Russia). Results. Cystatin C concentration in serum of healthy persons was significantly higher as compared to tear and intraocular fluids. In patients with choroidal melanoma, increased cystatin C concentration was similar in tear fluid of both the eyes. Lactoferrin level in tear fluid of healthy persons was significantly higher than its serum level. Significantly increased lactoferrin concentration in tear fluid was noted in patients with benign and malignant eye tumors. Conclusion. Increased level of cystatin C in tear fluid seems to be a possible diagnostic factor in the eye tumors studied. However, it does not allow us to differentiate between malignant and benign eye tumors. Similar changes were noted for lactoferrin in tear fluid. Keywords: choroidal melanoma; cystatin C; lactoferrin; eye biological fluids; tears; serum

ystatins belong to the group of endogenous inhibitors of cysteine proteases, which are important in clinical and experimental medicine (1,2). The main functions of cystatins are related to the inhibition of cysteine proteases, cell proliferation, cell migration and cell differentiation (3,4). Cystatins A and B (belonging to type 1) are mainly intracellular inhibitors; cystatins C, D, E/M, F, G, S, SN and SA are extracellular cystatins (belonging to type 2). Cystatins SA, S and SN were found primarily in saliva. Cystatins S and SN can also be expressed in tears, urine and seminal fluid (4). Cystatin C was shown to play a role in protein catabolism, cancer development, regulation of hormone

C

284

processing and bone resorption, modulating inflammation (5,6). Increased cystatin C level has been found in the serum of patients with several inflammatory diseases, such as colorectal tumors with metastases (7). Cystatin C as well as cystatins B, SN, SA and S was identified in tear fluid (4). Among the cystatin type 2 superfamily, cystatin C is the most studied; it is expressed in brain, thymus and epididymis. Cystatin C is produced at a constant rate by all types of cells and localized mainly in extracellular fluids; the high concentration was shown in cerebrospinal fluid, and in lower concentrations in milk, synovial fluid, serum, urine and bile (8,9). In eye fluids (less studied as compared to other biological fluids), cystatin C as a


Cystatin C and lactoferin in eye tumor development

secreted protein was suggested to play the role of inhibiting all cysteine proteases, such as cathepsins B, L, S (1012). It was shown recently that some members of the cystatin superfamily (cystatin A) have antiapoptotic properties linked with neoplastic changes in squamous cell epithelium. Therefore, it has been proposed as a diagnostic and prognostic marker of lung cancer (13). Recently, cystatin C was suggested as a prognostic factor in multiple myeloma (14), in the diagnostics of early-stage and inflammatory breast cancer (15). However, the role of cystatin C in eye tumors has not been studied in detail. Lactoferrin is a 78,000-Da metal-binding single-chain glycoprotein found in milk, tear fluid and other biological exocrine secretions (16,17). Lactoferrin has bacteriostatic properties in vitro and some anti-tumor activity (16,18). Since the human lactoferrin gene has been cloned, overexpression and large-scale lactoferrin production are now possible. Choroidal melanoma is one of the most aggressive malignant and most observed among eye tumors. Until now, there have been difficulties in differential diagnostics of choroidal melanoma with numerous eye tumors, mainly with benign tumors, as well as with so-called pseudotumorous disorders. Pseudo-tumors included disciform macular degeneration, sub-retinal hemorrhage, Coats’ disease (very rare congenital, nonhereditary eye disorder) and so on. Therefore, the search for possible new tumor biomarkers among different types of eye tumors is still important. The aim is to investigate the role of cystatin C in eye tear fluid and anterior camera of eye locally, and in serum and lactoferrin, revealing anti-tumor activity in eye tumor development (choroidal melanoma).

Materials and methods Design of the study A total of 43 patients with choroidal melanoma and 11 with benign eye tumors and pseudo-tumorous disorders (undergoing examination and treatment in Fedorov’s Centre for Eye Surgery) and 24 controls (healthy persons, medical doctors) were enrolled in this study. All patients were undergoing standard ophthalmologic examinations, including visiometric analysis, perimetry and visual field research, tonometry, biomicroscopic examination, ophthalmoscope examination and ultrasound exam (Bscanning). In several special cases, the following additional methods were used: ultrasound eye biomicroscopy, optical coherent tomography of retina, duplex eye scan with the dopplerography examination of vessels. The group of patients with choroidal melanoma included 43 persons aged 2880 (56.9915 years; males: 15, females: 28). Their vision was from 0 to 1.0. In all patients, ultrasound examination revealed plus-tissue (with low or middle echo-density) growing from the vessels. In most of the patients (42), the tumor process was noted in one eye,

in 1 patient in both eyes (simultaneously with breast cancer). The eye tumor length (height) was from 1.2 to 14.7 mm, diameter of the tumor basement from 8.2 to 27.6 mm. In 17 cases with large-sized tumors, surgery was carried out (enucleating). Histological study revealed the appearance of round-cellular melanoblastoma (7 cases), spindle-cell malignant melanoma (6 cases), epithelial type of melanoblastoma (2 cases) and melanoblastoma of the mixed type (2 cases). Benign eye tumors and pseudo-tumors group included 11 persons, aged 4274 (62.399.8 years); among them 1 male and 10 females. The patients with the following diagnosis were included in this group: agerelated macular degeneration 3 (vision from 0.001 to 0.1), sub-retinal hemorrhage 3 (vision from 0.001 to 0.01), iris-nevus syndrome (nevus of iridescent) 2 (vision 1.0) and nevus chorioidea 3 patients (vision 1.0). Ultrasound scanning revealed plus-tissue syndrome, with increased tissue from 0.5 to 4.7 mm with different echodensities. In 4 patients, duplex scanning with dopplerography examination did not reveal any plus-tissue and changes in blood vessels. Control group 24 healthy persons without ophthalmologic disorders, 2049 years old (22915) were used as a control. Four patients with cataracts aged 5881 were included in this group when uptake of anterior camera fluid was carried out during surgery. In addition, as a control for the study of serum cystatin C, 10 healthy persons aged 5165 years were included.

Sample collection Tear samples were collected using 10-mL capillary tubes without touching the eye globe or the lid. Intraocular fluid was taken from anterior eye camera during surgery. Serum was obtained after centrifuging blood samples at 3000g for 20 min at 48C (Eppendorf centrifuge 5415R, Hamburg, Germany) and stored at 708C until analysis. Cystatin C concentration in eye biological fluids and serum was measured by commercial ELISA kits for human cystatin C (BioVendor, Czechia). The antibodies used in ELISA are specific for human cystatin C. Analytical limit of detection (ALD) of cystatin C was 0.2 ng/mL. Detection of cystatin C did not interfere with hemoglobin (1.0 mg/ mL), bilirubin and triglycerides (5.0 mmol/L). The results were expressed in nanogram per milliliter. Lactoferrin concentration was assayed by commercial ELISA kits (Vector-BEST, Novosibirsk Region, Russia) according to the producer’s recommendations. The results were expressed in nanogram per milliliter. Statistical analysis All values were reported as the mean9SEM. The results were analyzed for statistically significant differences, using MannWhitney criteria and Student’s t-test.


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Results Cystatin C concentration in the serum of healthy persons (950.4921.2 ng/mL) was significantly higher (pB0.001) as compared to tear (371.3925.7 ng/mL) and intraocular fluids (765.6991.1 ng/mL, p B0.05). Among eye biological fluids studied, cystatin C level was higher in intraocular anterior camera fluid as compared to tears (pB0.001) (Table I). Therefore, concentration of cysteine protease inhibitor was presented as follows: serum intraocular fluid tears.

Choroidal melanoma Tear fluid cystatin C level in both the eyes increased (pB0.001), whereas concentration of this inhibitor in anterior camera fluid decreased (p B0.05) as compared to the control group (Table I). In choroidal melanoma, cystatin C level was increased similarly in the tear fluid of both the eyes (with and without tumor) versus control (Table I). Cystatin C concentration is serum was significantly increased (pB0.05) in choroidal melanoma. Therefore, in patients with choroidal melanoma cystatin C concentration was elevated in the tear fluid of both the eyes (with tumor and without tumor), whereas in serum similar changes were less prominent. Lactoferrin concentration in tear fluid of healthy persons (Table II) was significantly, approximately 10 times, higher than lactoferrin levels in the serum of the control (8001200 ng/mL) group. In anterior camera fluid of the control group, lactoferrin concentration was significantly (pB0.05) lower compared to that of the tear fluid and serum (Table II). Increased lactoferrin concentration was noted in tear fluid in patients with both benign (p B0.05) and malignant eye tumors (p B0.05) and in anterior camera fluid (p B0.05) in choroidal melanoma (Table II). In patients with choroidal melanoma, an increased level of lactoferrin was shown both in tear fluid of a tumordamaged eye and tear fluid of an eye without tumor (Table II). There was no difference between increased level of lactoferrin in tear fluids of patients with choroidal melanoma and benign eye tumors (Table II). The role of

lactoferrin in eye tumor has not been studied enough until now. Recently, in some other tumors (breast cancer phenotypes), lactoferrin was shown to contribute to the development and invasiveness of this disorder (19).

Discussion The search for new non-invasive markers and predictors of tumors of different localization is important for clinical oncology, especially in rare tumors, such as melanoblastoma chorioidea, where it is impossible to get biopsy material. Moreover, this tumor can be treated only surgically (enucleation) at present, and early diagnosis is essential. Until now, the biological markers of melanoblastoma chorioidea are not known. The tear fluids have a special interest (availability of this biological fluid) for searching biological markers. According to hypothesis, many tumors to secrete both proteases of different classes and their endogenous inhibitors; disturbances in the balance of proteases/inhibitors play the important role in tumor growth and metastasizing processes (1). Therefore, the search among secreted proteins of biological fluids is of special interest. The changes in balance protease/inhibitors (increased expression and activity of proteases and decreased level of inhibitors) were shown in several malignancies as a result of increased consumption of inhibitors (7). Cystatin C was shown to be implicated in the invasiveness of human glioblastoma cells and as a result, sense transcripts of cystatin C may prove useful in cancer therapy. However, in some hemoblastoses (lymphoma, lymphogranulomatosis) opposite data were obtained: increased serum cystatin C level was revealed, and decreased cystatin C concentration in acute leukosis (9). Cystatin C belongs to known secreted inhibitors among the cystatin superfamily, which includes both extracellular and intracellular types of inhibitors of cysteine proteases. Cystatin C was shown to be secreted by different cell types, especially by activated macrophages, as well as by some tumor cells (3). The tear proteins play an important role in maintaining the ocular surface, and changes in their components

Table I. Cystatin C concentrations (ng/mL) in biological fluids in choroidal melanoma and benign eye tumors (m9SEM) Biological sample Tear fluid (eye with tumor)

Control

Choroidal melanoma

Benign tumors and pseudo-tumorous disorders

461.3917.2**#

471.5915.5**

(n42)

(n11)

496.6923.9**#

477.5917.4**

Tear fluid (eye without tumor)

371.3925.7# (n24)

(n33)

(n11)

Anterior camera fluid

765.6991.1#

585.9972.1*#

(n4)

(n11)

Blood serum

950.4921.2 (n10)

1212.9992.5* (n16)

778.8

*pB0.05, **p B0.001 versus the appropriate control. #p B0.001 versus serum of the same group. The number of patients is given in parenthesis.

286


Cystatin C and lactoferin in eye tumor development

Table II. Lactoferrin concentrations (ng/mL) in biological fluids in choroidal melanoma and benign eye tumors (m9SEM) Biological sample Tear fluid (eye with tumor) Tear fluid (eye without tumor) Anterior camera fluid

Control

Choroidal melanoma

Benign tumors and pseudo-tumorous disorders

13,3889274*

13,5569338*

11,8869213 (n20)

(n22)

(n9)

13,5649301* (n22)

13,7519359* (n9)

342927

581953*

(n6)

(n 6)

*pB0.05 versus control. The number of patients is given in parenthesis.

may reflect the disturbances in the health of the ocular surface. Tears can be used to study the proteomic responses in patients with inflammatory eye disorders, such as fungal keratitis (20) and possibly in tumor eye disorders. The proteomic analysis of tear fluids in healthy persons already showed some promising results in eye research; 491 proteins were identified, revealing a large number of proteases and protease inhibitors, such as cystatins B, C, SA, SN, S (21). In our study, cystatin C and lactoferrin levels in tear fluid of patients with choroidal melanoma did not relate with the size of the tumor and their localization. Further studies are necessary to reveal the role of other types of cystatins (such as cystatins CN, S) in eye fluids, which can be useful in differential diagnosis of eye malignancies. Cystatin C is present in high concentrations in the normal human and rat retinas and similarly expressed in normal human and mouse retinas; it was suggested that cystatin C could be involved in the regulation of photoreceptor degradation in retinas (11). Cystatin C also reveals some immunomodulatory activity, playing a role in antigen presentation (4,22). According to some experimental data, uptake of cystatin C by eye cells has been shown (11). In experiments in mice and rats, it was shown that cystatin C administered intravitreally in vivo is taken up into cells of the corneal endothelium and epithelium, the epithelial cells lining the ciliary processes and into cells in the neuroretina and the retinal pigment epithelium (11,12). The active, temperature-dependent uptake of cystatin C into several cell types (the same that contain endogenous cystatin C) in the cornea, ciliary body and retina was noted (11). The uptake of cystatin C indicates that the inhibitor may exert biological functions in intracellular compartments. It is also possible that this uptake system may regulate the extracellular levels of cystatin C in the eye (11,12). Possibly, there is the potential to use cystatins in the therapy of different eye disorder (including eye tumor) to increase the host cell resistance.

Conclusion Tear cystatin C and lactoferrin level, increased in malignant and benign eye tumors, seems to be a perspective for diagnostics in these disorders. However, it is impossible to

differentiate choroidal melanoma and benign eye tumors according to the level of cystatin C and lactoferrin in eye tear fluids.

Acknowledgements The authors are grateful to Dr. Brack I.V. for providing help in statistical analysis.

Conflict of interest and funding Ethical approval for the research was obtained from Ethical Committee of the Institute of Physiology of Siberian Branch of Russian Academy of Medical Sciences, Novosibirsk, Russia and was in accordance with the Helsinki Declaration of 1975, as revised in 2008. This work was partially supported by a grant from SB RAMS and the Far East Branch of RAMS for investigating natural immunomodulators.

References 1. Mussap M, Plebani M. Biochemistry and clinical role of human cystatin C. Crit Rev Clin Lab Sci. 2004;41:467550. 2. Magister S, Obermajer N, Mirkovic B, Svajger U, Renko M, Softic A, et al. Regulation of cathepsins S and L by cystatin F during maturation of dendritic cells. Eur J Cell Biol. 2012;91:391401. 3. Kos J, Lah TT. Cysteine proteinases and their endogenous inhibitors: target proteins for prognosis, diagnosis and therapy in cancer (review). Oncol Rep. 1998;5:134961. 4. Keppler D. Towards novel anti-cancer strategies based on cystatin function. Cancer Lett. 2006;235:15976. 5. Turk V, Bode W. The cystatins: protein inhibitors of cysteine proteinases. FEBS Lett. 1991;285:2139. 6. Bobek LA, Levine MJ. Cystatins inhibitors of cysteine proteinases. Crit Rev Oral Biol Med. 1992;3:30732. 7. Kos J, Krasovec M, Cimerman N, Nielsen H, Christensen IJ, Brunner N. Cysteine protease inhibitor stefin A, stefin B, and cystatin C in sera from patients with colorectal cancer; relation to prognosis. Clin Cancer Res. 2000;6:50511. 8. Mulaomerovic A, Halilbasic A, Cickusic E, Zavasnik-Bergant T, Begic L, Kos J. Cystatin C as a potential marker for relapse in patients with non-Hodgkin B-cell lymphoma. Cancer Lett. 2007;248:1927. 9. Korolenko TA, Cherkanova MS, Gashenko EA, Johnston TP, Bravve IY. Cystatin C, atherosclerosis and lipid-lowering therapy by statins. In: Cohen J, Ryseck LP, editors. Cystatins, protease inhibitors. New York: Nova Science; 2011. p. 187204. 10. Barka T, Asbell PA, van der Noen H, Prasad A. Cystatins in human tear fluid. Curr Eye Res. 1991;10:2534.


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11. Wasselius J, Ha˚kansson K, Johansson K, Abrahamson M, Ehinger B. Identification and localization of retinal cystatin C. Invest Ophthalmol Vis Sci. 2001;42:19016. 12. Wasse´lius J, Johansson K, Hakansson K, Abrahamson M, Ehinger B. Cystatin C uptake in the eye. Graefes Arch Clin Exp Ophthalmol. 2005;243:58392. 13. Butler MW, Fukui T, Salit J, Shaykhiev R, Mezey JG, Hackett NR, et al. Modulation of cystatin A expression in human airway epithelium related to genotype, smoking, COPD and lung cancer. Cancer Res. 2011;71:110. 14. Terpos E, Katodritou E, Tsiftsakis E, Kastritis E, Christoulas D, Pouli A, et al. Cystatin C is an independent prognostic factor for survival in multiple myeloma and is reduced by bortezomib administrayion. Haematologica. 2009;94:3729. 15. Decock J, Obermajer N, Vozelj S, Hendrickx W, Paridaens R, Kos J. Cathepsin H, cathepsin X and cystatin C in sera of patients with early-stage and inflammatory breast cancer. Int J Biol Markers. 2008;23:17. 16. Tomita M, Takase M, Bellamy W, Shimamura S. A review: the active peptide of lactoferrin. Acta Paediatr Jpn. 1994;36: 58591. 17. Mann DM, Romm E, Migliorini M. Delineation of the glycosaminoglycan-binding site in the human inflammatory response protein lactoferrin. J Biol Chem. 1994;269:236617. 18. Wei M, Xu Y, Zou Q, Tu L, Tang C, Xu T, et al. Hepatocellular carcinoma targeting effect of PEGylated liposomes modified with lactoferrin. Eur J Pharm Sci. 2012;46:13141.

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19. Ha NH, Nair VS, Reddy DN, Mudvari P, Ohshiro K, Ghanta KS, et al. Lactoferrin-endothelin-1 axis contributes to the development and invasiveness of triple-negative breast cancer phenotypes. Cancer Res. 2011;71:725969. 20. Ananthi S, Chitra RT, Bini R, Prajna NV, Lalitha P, Venkataswamy G. Comparative analysis of the tear protein profile in mycotic keratitis patients. Mol Vis. 2008;14:5007. 21. de Souza GA, Godoy MF, Mann M. Identification of 491 proteins in the tear fluid proteome reveals a large number of proteases and protease inhibitors. Genome Biol. 2006;7:R72. 22. Mirkovic B, Premzl A, Hodnik V, Doljak B, Jevnikar Z, Anderluh G, et al. Regulation of cathepsin B activity by 2A2 monoclonal antibody. FEBS J. 2009;276:473951. *Tatyana A. Korolenko Institute of Physiology of Siberian Branch of the Russian Academy of Medical Sciences Novosibirsk, Timakov Str. 4, 630117 Russia Tel: 7 383 3348956 Fax: 7 383 3359754 Emails: [email protected]; [email protected]


CHRONIC DISEASE æ

HPV genotypes detected in cervical cancers from Alaska Native women, 19802007 Janet J. Kelly1*, Elizabeth R. Unger2, Eileen F. Dunne2, Neil J. Murphy1, James Tiesinga1, Kathy R. Koller1, Amy Swango-Wilson1, Dino Philemonof1, Xay Lounmala1, Lauri E. Markowitz2, Martin Steinau2 and Thomas Hennessy3 1

Alaska Native Tribal Health Consortium, Anchorage, AK, USA; 2Centers for Disease Control, Atlanta, GA, USA; 3Centers for Disease Control, Anchorage, AK, USA

Background. Human papillomavirus (HPV) vaccine prevents cervical pre-cancers and cancers caused by HPV types 16 and 18. This study provides information on the HPV types detected in cervical cancers of Alaska Native (AN) women. Methods. Cases of invasive cervical cancer diagnosed in AN women aged 18 and above between 1980 and 2007 were identified from the Alaska Native Tumor Registry. A representative formalin-fixed, paraffinembedded archived pathology block was retrieved and serially sectioned to allow histologic confirmation of lesion (first and last sections) and PCR testing of intervening sections. Extracted DNA was tested for HPV using Linear Array HPV Genotyping Test (Roche Diagnostics) with additional INNO-LiPA HPV Genotyping Assay (Innogenetics) testing on negative or inadequate specimens. All specimens were tested for a minimum 37 HPV types. Results. Of 62 cervical cancer specimens evaluated, 57 (91.9%) contained one or more HPV types. Thirty-eight (61.2%) cancers contained HPV types 16 or 18, and 18 (29%) contained an oncogenic type other than type 16 or 18. Conclusions. Overall, almost two-thirds (61.2%) of the archived cervical cancers had detectible HPV types 16 or 18, a finding similar to studies of US women. As expected, a proportion of cancers would not be prevented by the current vaccines. HPV vaccination and cervical cancer screening are important prevention strategies for AN women. Keywords: Alaska Native; HPV; cervical cancer; HPV genotypes

here are an estimated 11,000 cervical cancers each year in the United States; the cervical cancer burden among Alaska Native (AN) women is 10.3 per 100,000 and ranks 8th in the number of cancer diagnosed in AN women. Cervical cancer rates were four times higher in AN women than in US white women during the 1970s to early 1980s, but, through increased screening and treatment activities, rates have since decreased to be similar to the overall US average (1). HPV vaccines offer new opportunities for primary prevention of these cancers; both the bivalent HPV vaccine (Cervarix, GSK) and the quadrivalent HPV vaccine (Gardasil, Merck) are licensed and recommended for routine use in 11- or 12-year-old girls for the prevention of cervical cancer (2). Infection with HPV causes virtually all cervical squamous cell carcinomas and cervical adenocarcinomas

T

(35). Studies of invasive cervical cancers demonstrate that up to 99% of cervical cancer specimens have HPV detected (47). Of approximately 40 HPV types identified in the genital tract, at least 15 are considered carcinogenic (7). In the United States and worldwide, more than two-thirds of cervical cancers are due to HPV 16 and 18 (6,8). While studies have evaluated different regions and countries, few have described genotypes in specific populations. A prior study of cervical cancer specimens from 1980 to 1989 found that HPV 16 was the most prevalent genotype in AN women: prevalence of HPV 16 was 77% in AN, 81% in Greenland Natives and 70% in Danish whites (9). In this study, 43% of HPV-positive AN specimens contained multiple HPV genotypes compared to 4% in Greenland Natives and 8% in Danish whites. HPV 31 and 33 were more frequently detected in AN


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Janet J. Kelly et al.

specimens (21 and 30%, respectively) than in specimens from Greenland Native (3% each HPV 31 and 33) or Danish white (0% HPV 31 and 6% HPV 33). Our study assessed HPV genotypes found in invasive cervical cancer specimens from AN women diagnosed from 1980 to 2007. The purpose was to characterize the preventable burden of HPV-associated cervical cancers in AN women to assess the potential impact of HPV vaccination on cervical cancer in this population.

Table I. Age, ethnicity, tumor stage, diagnosis year and geographic distribution of Alaska Native women with invasive cervical cancer, and Alaska Native women with cervical cancer specimens available, 19802007 Age range (years)

1689

2380

Mean

42.5

44.4

Median

41

41

%

%

Inupiaq/Yupik

43.9

54.8

Methods

Athabascan

44.6

30.6

Invasive cervical cancer diagnosed from 1980 to 2007 in AN women living in Alaska aged 18 years and older were identified through the Alaska Native Tumor Registry (10). One representative formalin-fixed, paraffinembedded block of the primary tumor was selected from each case at the Alaska Native Medical Center (ANMC). Serial sections were cut using precautions to prevent HPV contamination between blocks. The first and last sections were stained with hematoxylin and eosin, and they were reviewed by a study pathologist to confirm the histology. An intervening 10-micron section was extracted using the previously described high-temperature xylene-free method yielding a 100-mL extract (11). All extracts were tested with the Linear Array HPV Genotyping Test (Roche Diagnostics), which detects 37 HPV types (6, 11, 16, 18, 26, 31, 33, 35, 39, 40, 42, 45, 51, XR(52), 53, 54, 55, 56, 58, 59, 61, 62, 64, 66, 67, 68, 69, 70, 71, 72, 73, 81, 82, 83, 84, 89, IS39) and includes b-globin as an endogenous control. Samples with negative or inadequate (HPV and b-globin negative) results were re-tested with the INNO-LiPA HPV Genotyping Assay (Innogenetics). LiPA detects 29 HPV types (6, 11, 16, 18, 26, 31, 33, 35, 39, 40, 43, 44, 45, 51, 52, 53, 54, 56, 58, 59, 66, 68, 69, 70, 71, 73, 74, 81, 82) and includes HLA-DPB1 as an endogenous control. Inadequate samples (HPV negative and endogenous control negative) in both assays were excluded from this analysis. Fifteen HPV genotypes 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73 and 82 are considered oncogenic in this analysis (7). The protocol was approved by the Alaska Area IRB, Southcentral Foundation Scientific Review Board and the Alaska Native Tribal Health Review Board.

Aleut

11.5

14.5

Results From 1980 to 2007, a total of 139 AN women were diagnosed with invasive cervical cancer while a resident of Alaska. Among these, a total of 136 were ]18 years of age and 90 were diagnosed at the ANMC in Anchorage, Alaska. Archived tissues were located for 71 (79%) of ANMC cases 18 years and 62 (69%) contained representative cervical tumor. The median age of the 62 women with an archived specimen available was 41 years, the same as the median age for all AN women diagnosed with invasive cervical

290

Ethnicity (n62)

SEER summary stage

%

%

Local Regional

58.7 28.4

52.0 36.0

Distant

10.1

12.0

Unknown

2.7

0

%

%

19801984

25.5

24.3

19851989

21.9

11.2

19901994

16.3

17.7

19951999

14.2

17.7

20002004 20052007*

9.9 12.0

12.9 16.1

Year of diagnosis

Geographic region (IHS Service Unit)

%

%

Anchorage

34.0

46.8

Fairbanks

15.6

3.2

Yukon-Kuskokwim

16.3

24.2

Southeast

10.6

4.8

Kotzebue

7.1

4.8

Ketchikan

5.7

3.2

Norton Sound Arctic Slope

5.7 2.8

4.8 3.2

Bristol Bay

2.1

4.8

cancer during the period 19802007 (Table I). Among women diagnosed during years 19842007, for which SEER Summary Stage was available, stage at diagnosis was similar (local, regional, distant and unknown stages) to all AN women diagnosed with invasive cervical cancer. Year of diagnosis was similar except for years 19851989 when proportionately fewer specimens were available. The majority of specimens were for women from Anchorage (47%) and women from the Yukon-Kuskokwim area (24%) of Alaska who presented or were referred to the Anchorage facility than for women living in other areas of Alaska. All 62 tissue specimens available for HPV typing yielded adequate results: 57 (91.9%) had HPV detected; 56 (90.3%) specimens were positive for one or more HPV types considered oncogenic (Table II). HPV 16 was detected in half of all specimens (31/62, 50%) and HPV 16 or 18 were detected in 61.3% (38/62) of specimens.


HPV genotypes in cervical cancers from Alaska Native women

Table II. Number and percentage of HPV genotypes detected in invasive cervical cancer specimens, Alaska Native women, 19802007 (N62) HPV type

Number

%

16

26

41.9

18

6

9.6

166a 1618

1 2

1.6 3.2

1633

1

1.6

1654a

1

1.6

1868

1

1.6

31

1

1.6

3368

1

1.6

33

3

4.8

3959 45

1 3

1.6 4.8

58

1

1.6

59

5

8.0

73

2

3.2

82

1 1

1.6 1.6

57c

91.9

69b Total a

Low-risk HPV type. Non-oncogenic HPV type. c HPV was not detected in 5 specimens. b

HPV 16 was detected as a single infection in 41.9% (26/ 62). Eighteen (29%) specimens had oncogenic HPV other than HPV 16 and 18. One (1.6%) specimen had only HPV 69 detected. Two HPV genotypes were detected in 12.9% of specimens, and no specimens had more than 2 HPV genotypes detected. The histologic types identified from 62 specimens were: squamous cell carcinoma (84%), adenocarcinoma (11%), and carcinoma, not otherwise specified (5%). Among the squamous cell carcinomas, HPV 16 was detected in 48% and HPV 18 in 12%. Among the adenocarcinomas, HPV 16 was detected in 29% and HPV 18 in 29%.

Discussion This study of cervical cancers in AN women found that 61% of tumors had evidence of HPV 16 or HPV 18. This is similar to findings from other studies on US women, in which approximately 70% of tumors were attributed to HPV 16 or 18 (2,7). An HPV vaccine targeting oncogenic genotypes 16 and 18 could reduce cervical cancers in AN women by nearly two-thirds. If there is protection against other vaccine-related oncogenic types, through crossprotection or through new formulations of vaccine with different virus-like particles, vaccination could result in further reductions of cervical cancer (12,13). It is important to note, one-third of HPV genotypes in our specimen population contained other oncogenic nonHPV 16 or non-HPV 18 genotypes alone (29%); types

not targeted by the current vaccines. Regular cervical cancer screening for women at least 21 years or older is currently recommended for all women regardless of vaccination status. Our study found some differences in HPV types in cervical cancer compared to the only prior study in AN women. In the prior study of cervical cancer specimens from AN women diagnosed from 1980 to 1989, 53 formalin-fixed and paraffin-embedded cervical cancer biopsies were assayed by PCR for 6 HPV genotypes (16, 18, 31, 33, 35 and 45) (9); overall, 98% were HPV positive. A higher percentage of HPV 16 alone (79% vs. 50%) and a lower percentage of HPV 18 alone were found in the prior study compared to this study (4% vs. 15%). The second most common HPV genotype in the earlier Alaska study was HPV 33 (30%); in this study, only 5 cases (8%) contained HPV 33. Multiple HPV genotypes were detected in 36.5% of cancer specimens in the earlier study, while this study found multiple genotypes in only 12.9% of tissues. Our study used different methods to reduce sample-to-sample viral carryover during thinsection preparation and different DNA extraction methods that most likely account for these differences. Twelve cases that were used in the prior study were retested in this study, although they were not necessarily the same tissue block. Of these 12, 9 (75%) were concordant for HPV genotype. In 2 of the 3 discordant cases, HPV genotype 16 was found by both methods, but the prior study detected additional HPV types not found using the current methods. The third discordant case revealed genotype 33 using the current methods versus genotype 16 in the prior study. Thus, in cases tested in both studies, the finding of a high percentage of multiple HPV genotypes was not corroborated using the current methods. One limitation of this study is that samples were selected based on the availability at one hospital pathology laboratory and may not be representative of all AN women with cervical cancer. Of the 90 individuals who received a diagnosis at ANMC, only 62 (69%) individuals had a cervical cancer specimen available. Possible reasons for unavailable tissue blocks include loss of specimen due to errors in labeling or misfiling in trays in the pathology laboratory, the storage box unlocatable in archives, or the cervical cancer specimen was completely used up in prior study. It is also important to note the classification of high-risk types depends on the study and methods. Munoz et al. classified 15 types as high risk, or oncogenic, and another three as possible oncogenic, types 26, 53 and 66 (7). Studies in which HPV genotypes are detected in invasive cervical cancer provide important information to understand the impact HPV vaccines might have on reducing cervical cancer in defined populations. To date, most studies of different regions/ethnicities find similar proportions of cancers caused by HPV 16 or 18.


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Our study on AN women found a lower prevalence due to HPV 16 or 18, but given smaller numbers this is consistent with other studies. Evaluations of cancers due to HPV 16 and 18 in specific populations as well as vaccine impact monitoring on cancer reduction is warranted. One-third of all cervical cancers are caused by HPV types not prevented by vaccine, and provide support for continued Pap screening.

7.

8.

9.

Conclusions Overall, almost two-thirds (61.2%) of the archived cervical cancers had detectible HPV types 16 or 18, a finding similar to studies of US women. As expected, a proportion of cancers would not be prevented by the current vaccines. HPV vaccination and cervical cancer screening are important prevention strategies for AN women.

10.

11.

12.


References 13. 1. Lanier A, Kelly J, Maxwell J, McEvoy T, Homan C. Cancer in Alaska Native People, 19692003. AK Med. 2006;48:3059. 2. Markowitz L, Dunne E, Saraiya M, Lawson H, Chesson H, Unger E. Quadrivalent human papillomavirus vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2007;56:124. 3. National Cancer Institute at the National Institutes of Health. Cervical cancer; Available from: http://www.cancer.gov/cancer topics/types/cervical; Accessed on May 27, 2011. 4. Walboomers J, Jacobs M, Manos M, Bosch FX, Kummer JA, Shah KV, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol. 1999;189:13. 5. Bosch F, de Sanjose S. Human papillomavirus and cervical cancer burden and assessment of causality. J Natl Cancer Inst Monogr. 2003;31:313. 6. Clifford GM, Gallus S, Herrero R, Munõz N, Snijders PJF, Vaccarella S. Worldwide distribution of human papillomavirus types in cytologically normal women in the international

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agency for research on cancer HPV prevalence surveys: a pooled analysis. Lancet. 2005;366:9918. Munoz N, Bosch F, Sanjose S, de Herrero R, Castellsague X, Shah K, et al. Epidemiologic classification of human papillomavirus types associated with cervical cancer. N Eng J Med. 2003;348:51827. Dunne E, Unger E, Sternberg M, McQuillan G, Swan D, Patel S, Markowitz L. Prevalence of HPV infection among females in the United States. JAMA. 2007;297:8139. Sebbelov A, Davidson M, Kjaer S, Jensen H, Gregoire L, Hawkins I, et al. Comparison of human papillomavirus genotypes in archival cervical cancer specimens from Alaska Natives, Greenland Natives and Danish Caucasians. Microbes Infect. 2000;2:1216. Alaska Native Tumor Registry. Anchorage, Alaska: Alaska Native Epidemiology Center, Alaska Native Tribal Health Consortium; 2011. Steinau M, Patel S, Unger E. Efficient DNA extraction for HPV genotyping in formalin-fixed paraffin-embedded tissues. J Mol Diag. 2011;13:37781. Brown D, Kjaer S, Iversen O, Hernandez-Avila M, Wheeler C, Perez G, et al. The impact of quadrivalent human Papillomavirus (HPV; types 6, 11, 16, and 18) L1 virus-like particle vaccine on infection and disease due to oncogenic nonvaccine HPV types in generally HPV-naı¨ve women aged 1626 years. J Infect Dis. 2009;199:92635. Wheeler C, Kjaer S, Sigurdsson K, Iversen O, HernandezAvila M, Perez G, et al. The impact of quadrivalent human papillomavirus (HPV types 6, 11, 16, and 18) L1 virus-like particle vaccine on infection and disease due to oncogenic nonvaccine types in generally HPV-naı¨ve women aged 1626 years. J Infect Dis. 2009;199:93644.

*Janet J. Kelly Alaska Native Tribal Health Consortium Division of Community Health Services Epidemiology Center 4000 Ambassador Drive Anchorage AK 99508 USA Tel: 1-907-729-3949 Fax: 1-907-729-4569 Email: [email protected]


CHRONIC DISEASE æ

Preliminary analysis of immune activation in early onset type 2 diabetes Julia D. Rempel1,2,3*, Juliet Packiasamy1, Heather J. Dean3,4, Jonathon McGavock3, Alyssa Janke1, Mark Collister1,2, Brandy Wicklow3,4 and Elizabeth A. C. Sellers3,4 1

OOH-QUIN Immunology Laboratory, Section of Hepatology, Department of Internal Medicine, Manitoba Institute of Child Health, Winnipeg, Canada; 2Department of Immunology, University of Manitoba, Winnipeg, Canada; 3Manitoba Institute for Child Health, University of Manitoba, Winnipeg, Canada; 4Department of Pediatrics, University of Manitoba, Winnipeg, Canada

Introduction. First Nations and other Aboriginal children are disproportionately affected by cardiometabolic diseases, including type 2 diabetes (T2D). In T2D, the disruption of insulin signalling can be driven by proinflammatory immunity. Pro-inflammatory responses can be fueled by toll-like receptors (TLR) on immune cells such as peripheral blood mononuclear cells (PBMC, a white blood cell population). TLR4 can bind to lipids from bacteria and food sources activating PBMC to produce cytokines tumour necrosis factor (TNF)-a and interleukin (IL)-1b. These cytokines can interfere with insulin signalling. Here, we seek to understand how TLR4 activation may be involved in early onset T2D. We hypothesized that immune cells from youth with T2D (n 8) would be more reactive upon TLR4 stimulation relative to cells from age and body mass index (BMI)matched controls without T2D (n 8). Methods. Serum samples were assayed for adipokines (adiponectin and leptin), as well as cytokines. Freshly isolated PBMC were examined for immune reactivity upon culture with TLR4 ligands bacterial lipopolysaccharide (LPS, 2 and 0.2 ng/ml) and the fatty acid palmitate (200 mM). Culture supernatants were evaluated for the amount of TNF-a and IL-1b produced by PBMC. Results. Youth with T2D displayed lower median serum adiponectin levels compared to controls (395 vs. 904 ng/ml, pB0.05). PBMC isolated from youth with and without T2D produced similar levels of TNF-a and IL1b after exposure to the higher LPS concentration. However, at the low LPS dose the T2D cohort exhibited enhanced IL-1b synthesis relative to the control cohort. Additionally, exposure to palmitate resulted in greater IL-1b synthesis in PBMCs isolated from youth with T2D versus controls (p B0.05). These differences in cytokine production corresponded to greater monocyte activation in the T2D cohort. Conclusion. These preliminary results suggest that cellular immune responses are exaggerated in T2D, particularly with respect to IL-1b activity. These studies aim to improve the understanding of the biology behind early onset T2D and its vascular complications that burden First Nations people. Keywords: early onset type 2 diabetes; TLR4; interleukin 1beta

etabolic syndrome (MetS) and type 2 diabetes (T2D) present a significant burden to Canadian First Nations and other Indigenous populations (1). More troubling is that these metabolic diseases, which were once restricted to adults, are becoming increasingly prevalent in children and youth (2). Within Canada, Manitoba has the highest incidence of early onset T2D, with First Nations being disproportionately affected (3,4). The increasing prevalence of T2D among Indigenous youth worldwide can be attributed to both genetic and environmental factors (5,6). Significant environmental changes include a shift away from traditional food to nutrient sparse, calorie dense, westernized food, as well as

M

an increasing sedentary lifestyle. The shift away from a more traditional lifestyle is reflected in the considerable rates of obesity within First Nations youth in Canada (7,8). Obesity is a significant determinant of MetS and T2D (9,10). In one First Nations community, obese children had a 5.1 odds ratio (95% CI 1.51, 17.0) of developing T2D before the age of 18 years (11).

Adipose tissue as immune tissue in T2D The immune system is a critical mediator in the onset of T2D. Adipose tissue is not inert, but acts as inflammatory immune tissue. Adipose tissue consists of adipocytes that secrete adipokines or ‘‘fat hormones’’ such as apidonectin


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and leptin. These adipose-derived hormones influence insulin sensitivity and therefore play a role in maintaining normal glucose levels. Adiponectin levels are decreased in states of metabolic disease; whereas, leptin concentrations are often increased (12,13). However, the role of adipokines in the natural history of early onset T2D is poorly understood.

Toll-like receptor 4 and sterile inflammation Adipose tissue also contains macrophages, which can account for more than 25% of cells within the adipose tissue (14). When macrophages move into the blood stream they take on different characteristics and are called monocytes. Macrophage/monocytes interact with lipids through receptors on their surface including toll-like receptor (TLR)4. TLR4 is important in protecting the body from bacterial infections through binding lipopolysaccharides (LPS) found on the surface of Gram-negative bacteria such as E. coli. The binding of TLR4 to LPS in a bacterial infection results in the macrophages/monocytes becoming activated allowing them to produce pro-inflammatory cytokines, which assist in clearing the infections. However, chronic exposure to these cytokines can be harmful. Chronic cytokine exposure can occur upon consumption of diets high in lipids. These lipid complexes can also bind TLR4 receptors causing cells to become activated. Palmitate is a fatty acid that is present in many foods. Increased serum palmitate levels are associated with a high degree of liver steatosis (15). In addition, palmitate exposure can increase TLR4 levels on macrophage cell lines 8-fold, as well as activate TLR4 resulting in proinflammatory cytokine production (16). Similar findings were observed with human monocytes (16).

Cytokines in T2D Many cytokines have been implicated in obesity-induced inflammation and T2D. Our focus has been on tumour necrosis factor (TNF)-a, interleukin (IL)-1b and IL-6. These cytokines can impair insulin signalling or induce b-cell apoptosis (1719). However, it is only in cases of extreme immune activation that cytokine spillage into the blood stream occurs. Thus, examination of TLR4 responsiveness requires an assessment of cellular activity.

Immunity in Manitoban Indigenous populations TLR4 activation can upset the normal balance of the immune system promoting insulin resistance. This can lead to an increased risk for cardiovascular and other diseases (2022). The relevance of TLR4-induced cytokine activity in early onset diabetes in Aboriginal peoples is unknown. Serological studies, examining immune markers in the serum have had limited findings (23). However, previous studies by our unit and others indicated a marked difference in immune genetics between Manitoban Indigenous peoples and Caucasians

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(5,6,24). An assessment of cellular immune function, examining peripheral blood mononuclear cell (PBMC) cytokine production, also indicated that First Nations adults have greater inflammatory responses than Caucasians (5). The heightened pro-inflammatory immunity observed in these studies, concomitant with stressful environments and changes in lifestyle, could promote an earlier onset of T2D. Altogether, these factors could enhance susceptibility to, and progression of, T2D, as well as promote the high prevalence of T2D-related co-morbidities observed in this young population (2527).

Study goal The purpose of this study is to evaluate systemic (evaluated in serum) and cellular (examined with PBMC) immunity in youth with T2D relative to ageand body mass index (BMI)-matched normoglycemic youth to determine the role of the immune system in early onset T2D. We hypothesized that immune cells from youth with T2D would be more reactive upon TLR4 stimulation compared to PBMC from youth without T2D.

Methods Subjects This study was approved by the University of Manitoba Research Ethics Board and Health Sciences Centre (HSC) Research Board, Winnipeg, Manitoba. In addition to ethical approvals, progress reports were presented to the Manitoba First Nation Diabetes Committee, an advisory committee of individuals who work in Manitoban First Nations communities, which is funded by the diabetes programme of the First Nations and Inuit Health Branch of Health Canada. Youth with T2D were recruited through the paediatric endocrinology clinic, Winnipeg Children’s Hospital, Winnipeg, MB. Overweight youth without T2D were recruited through the Manitoba Institute of Child Health, a research unit serving a large geographic region of central Canada. Youth (1418 yrs old) qualifying for the study were approached by a clinical research coordinator. Written informed consent was given by parents or guardians. Participants provided a signature of assent to state agreement to their involvement. A short questionnaire inquiring about general health, co-morbidities and medications was also administered. Ethnicity was selfdeclared as First Nations or Me´tis. All other groups were designated as non-Aboriginal. Individuals with chronic infections, chronic inflammatory disease and/or signs of acute infection (cold, flu, malaise) were not recruited. We also excluded individuals with the known hepatic nuclear factor (HNF)-1a G319S polymorphism (GS or SS genotype). The HNF-1a G319S


Immune activation in type 2 diabetes

polymorphism is a private polymorphism associated with T2D in the Oji-Cree First Nations population in Manitoba and northwestern Ontario. It results in a mild insulin secretory defect and is associated with early onset T2D in this population (28,29).

Clinical parameters Participants were weighed in kilograms using a standard office scale. Height (in centimetres) was assessed using a stadiometer. BMI was computed from height and weight (height/m2). Obesity was defined as]95 percentile for age and gender (30). Blood pressure was measured in the sitting position using a standard sphygmomanometer. Clinical chemistry was determined at the Clinical Chemistry Department, HSC. Blood sample collection and PBMC isolation Serum samples and whole blood were collected in the morning. Serum samples were stored at 808C until analysis of cytokines by ELISA. ELISAs were performed as previously described (31). Adiponectin and leptin ELISAs were purchased from R&D Systems (Minneapolis, MN, USA). PBMC are a white blood subset containing monocytes and lymphocytic cells including T cells and B cells. PBMC were isolated from whole blood with Ficoll (Sigma, St. Louis, MO, USA) as previous described (5,31). Cells consistently exhibited 98% viability (5,31). In vitro culture and cytokine protein analysis Freshly isolated PBMC were cultured at 0.25 106 cells/ ml in 96-well round bottom plates (Corning Inc., Corning, NY, USA) and incubated with culture medium, TLR4 ligands LPS (2 and 0.2 ng/ml, Sigma) or palmitate (200 mM, Sigma) conjugated to bovine serum albumin. Palmitate was conjugated as previously described (16). Supernatants were harvested 24 hours later for the detection of cytokine levels. Intracellular cytokine staining Briefly, freshly isolated PBMC were cultured (0.25 106 cells/well) in the presence of medium, LPS (20 ng/ml) or palmitate (200 mM) along with Brefeldine A (10 mg/ml, BD Biosciences) for 4 hours. Brefeldine A inhibits secretion of protein from cells. At 4 hours, cells were washed. Fluorochrome-conjugated anti-CD14, an antibody that detects monocytes, was added for 30 minutes at 48C. Cells were washed with 0.01% saponin solution to permeablize the cells so that the antibodies could penetrate the cell membrane. Fluorochrome-conjugated antibodies for intracellular staining against TNF-a and IL-1b were added for 30 minutes in the dark. Cells were washed and stored at 48C in the dark. The next day, the data were acquired on a BD FACSCanto II flow cytometer. This machine allows visualization of the fluorochromes so that the percentage

of cells bound by corresponding antibodies can be assessed.

Data analysis Categorical differences were determined by x2 Fisher’s exact test. The Mann-Whitney test was used to determine if significant differences existed between the presence and absence of T2D. Spearman’s correlation was used to determine relationships between immune and clinical parameters. pB0.05 was considered significant.

Results Patient demographics This preliminary report details findings from youth with (n8) and without (n 8) T2D. Demographic profiles were similar, except that the T2D cohort contained a greater percentage of First Nations youth relative to the non-T2D cohort (p B0.05, Table I). Youth with T2D also displayed slightly higher resting systolic blood pressure (pB0.05). Adiponectin levels were lower in early onset T2D Adiponectin concentrations were lower in the T2D cohort relative to the control cohort (p B0.01, Fig. 1); whereas leptin levels were similar between the groups. Leptin levels, however, positively correlated with BMI (pB0.01). Circulating TNF-a and IL-6 levels, an indication of systemic immune activation, were undetectable in these youth cohorts.

Table I. Study cohorts T2Db (n 8)

Control (n8)

Age (years)a

15 (1517)

16 (1417)

Female (%)

87.7

75

First Nation (%)

87.5

25*

Parameters Demographics

Me´tis (%)

0

25

12.5

50

BMIa

27 (22.242.2)

29 (25.138.7)

Blood pressurea Systolic (mmHg)a

129 (105139)

106 (102136)*

Diastolic (mmHg)a

67 (5784)

64 (5374)

Triglyceride (mmol/L)a

1.6 (0.63.5)

2.0 (13.4)

ALT (IU/l)a

20.0 (1046)

14.0 (1146)

AST (IU/l)a

21.5 (1131)

20.0 (1333)

Non-Aboriginal (%) Clinical and laboratory

a

Median and range shown. Quantitative data were assessed by MannWhitney. Categorical differences were determined by x2 Fisher’s exact test. *pB0.05 was considered significant. BMI, body mass index; ALT, alanine aminotransferase; AST, aspartate aminotransferase.

b


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Cellular immune sensitization to TLR4 activation in youth with and without T2D To assess whether sensitivity to TLR4 activation in T2D and obese youth cohorts differed, PBMC were incubated with culture medium, LPS (2 or 0.2 mg/ml) or palmitate. Independent of LPS or palmitate stimulation TNF-a production was comparable between T2D and control cohorts (Fig. 2A). IL-1b secretion was also similar between cohorts at the high LPS concentrations. In contrast, at the low LPS dose PBMC from the T2D cohort were more reactive for IL-1b synthesis than cells acquired from obese youth without T2D (medians, 1,745 vs. 705 pg/ml, p B0.05). Moreover, following palmitate activation PBMC secretion of IL-1b was 3.5-fold greater from the T2D cohort relative to their counterparts (medians, 2,927 vs. 849 pg/ml, p B0.05). TNF-a and IL-1b synthesis did not correlate with clinical parameters (data not shown). PBMC consist of monocyte and lymphocyte populations. Because of their putative role in T2D, monocyte reactivity to LPS and palmitate was directly examined with intracellular cytokine staining. A greater percentage of monocytes from the T2D cohort (n3) were actively

producing TNF-a and IL-1b in response to TLR4 activation by LPS than from monocytes from the control cohort (n3, Fig. 2B). Palmitate exposure for 4 hours also resulted in a greater percentage of monocytes from youth with T2D than youth without T2D being involved in TNF-a and IL-1b synthesis.

Discussion Inflammatory immunity stemming from adipose tissue is a critical factor in the onset and progression of T2D in adult human and animal models. The primary novel finding from this preliminary cross sectional study of immune reactivity in early onset T2D was that the immune response from youth with T2D was hyperreactive to long chain fatty acids compared to obese matched youth without T2D.

Adipokines Adiponectin levels are lower among overweight individuals with metabolic diseases, in particular dysglycemia (3235). The data presented here extend these findings by demonstrating that adiponectin concentrations were also lower in youth with T2D compared to normoglycemic

Fig. 1. Adipokine associations with disease parameters. Serum adiponectin and leptin concentrations were assessed by ELISA. A. Adiponectin levels were significantly lower in T2D youth, compared to obese matched controls. Horizontal bars indicate median values (Mann-Whitney, *p B0.05). B. Leptin concentrations correlated with BMI. Relationships were assessed by Spearman correlation (**pB0.01). Serum samples were also analyzed for cytokines TNF-a and IL-6 based on previous studies by group members. However, serum cytokines were undetectable in these subjects (data not shown).

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Fig. 2. T2D cohort demonstrates enhanced cellular sensitivity to TLR4 ligands than obese controls. A. PBMC from youth with (n8, grey bars) and without (n 8, white bars) T2D were cultured as described in Methods. Whisker plots show medians and ranges (Mann Whitney, *p B0.05). B. PBMC from youth with (n3) and without T2D (n3) were activated for 4 hrs with LPS and palmitate. Cells were stained as per Methods (ICCS). Shown are PBMC gated on the CD14 positive cells, the monocyte population. Red lines indicate responses to culture medium alone. Blue lines indicate responses to either LPS or palmitate as indicated. One set of 3 representative results is shown.

controls (Fig. 1A). Studies in Oji-Cree populations revealed that adiponectin levels are prognostic for (23,36). Whether hypoadiponectinemia is a cause or consequence of dysglycermia in youth has yet to be determined. Prospective cohort studies of obese youth are needed to determine its role in the natural history of early onset T2D.

Systemic immunity Systemic immunity reflects the background inflammatory status of the body, representing the ‘‘spill over’’ from cellular events. In adults, serum pro-inflammatory cytokines such as TNF-a and IL-6 are elevated in those with obesity and T2D relative to healthy controls (37). Here, serum TNF-a and IL-6 were undetectable. The absence of serum cytokines, a common finding in obese adults suggests that the duration of T2D affects the extent of systemic inflammation. In a study of 362 children, low

serum TNF-a levels did not correlate with metabolic syndrome or BMI (38). However, associations of proinflammatory cytokines with obesity in adolescents have been observed (33). Stringer et al. also found that serum IL-6, but not TNF-a, levels were higher in T2D (n 24) relative to obese matched (n 19) First Nations youth (23). The difference between the results of these studies is unclear. Both studies have a small sample size and different individual subjects.

Cellular immunity In addition, the susceptibility of PBMC to TLR4 activation was examined by culturing freshly isolated PBMC with LPS and palmitate. LPS- or palmitateinduced TNF-a did not differentiate with T2D diagnosis (Fig. 2A). Similar results were observed for IL-1b production upon activation with the higher LPS dose. However, at the low LPS dose (0.2 mg/ml), the cells


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derived from the T2D cohort secreted 2.3-fold more IL1b than their counterparts (pB0.05). Thus, in early onset T2D, peripheral immune cells appear to have a lower threshold for LPS-induced IL-1b synthesis. Moreover, palmitate activation induced higher median levels of IL1b from the T2D cohort versus the obese control cohort (2,927 vs. 849 pg/ml, pB0.05). This indicates that in early onset T2D, PBMC are more sensitive to low doses of the TLR4 activator LPS, as well as the fatty acid palmitate. Thus, it may be that the consumption of even low levels of lipids cause a greater inflammatory reaction for individuals with T2D than for obese individuals without T2D. PBMC consist of monocytes and lymphocytes. Macrophage/monocyte populations are key producers of proinflammatory cytokines (39). Here, monocyte behavior in early onset T2D (n 3) relative to obese controls (n3) was examined (Fig. 2B). Independent of TLR4 activator, the percentage of monocytes producing TNF-a and IL-1b was greater for the T2D cohort relative to the cohort without T2D. The difference in TNF-a activity observed between the PBMC cultures (24 hour) and the intracellular assays (4 hour) may suggest that initially monocytes are more reactive with respect to TNF-a production but level out with time. Although within a 4hour culture monocytes are the primary source of LPSand palmitate-induced TNF-a and IL-1b production (data not shown), the response of other cells within the PBMC may eventually dilute out the initial differences in monocyte activity. The greater reactivity of monocytes for IL-1b synthesis supports the findings with PBMC 24hour cultures, suggesting that the IL-1b response is more sustained.

Cytokine activity This dichotomy in TNF-a and IL-1b activity may reflect physiological differences between obese states relative to T2D. TNF-a has been implicated in the pathology underlying obesity and T2D. Nonetheless, there is inadequate information on PBMC TNF-a production in obesity or the metabolic syndrome in adults. Much less is known in paediatric populations (40). TNF-a-mediated processes may be more involved in the complications associated with T2D such as cardiovascular disease (41,42). Conversely, IL-1b is considered an instigator of metabolic disease due to its capacity to drive sterile inflammation (43). Extensive studies in humans and animal have found that IL-1b, or inflammasome components required for the secretion of IL-1b, are increased in metabolic disease (reviewed in Refs. 44,45). Moreover, treatment with IL-1b antagonists can improve glycaemia in adults with T2D and in animal models of T2D (46,47). Here, IL-1b levels did not correlate with physical parameters or clinical chemistry, but this may be due to the

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small sample size. The narrow BMI range may also have limited analysis of immune activity with respect to BMI.

Study limitations First, the sample size was small raising the likelihood of type 1 or 2 errors in the statistical analysis. This is particularly the case with the intracellular cytokine staining. Second, there were significantly more First Nations individuals in the T2D cohort compared to controls, making it possible that this was an effect based on ethnic differences in immunity. However, when analyzed against ethnicity IL-1b production after exposure to LPS or palmitate did not differ between First Nations and nonFirst Nations individuals (data not shown). In addition, IL-1b synthesis by PBMC from First Nations with T2D (n7) was 3- and 4-fold greater than that from First Nations without T2D (n2) following culture of cells with LPS (0.2 mg/ml) and palmitate, respectively (data not shown). Taken together, this supports the premise that the difference in IL-1b activity is due to the presence of T2D and not due to differences in ethnicity. Finally, the exact relationship between the behavior of peripheral PBMC or monocytes and adipose tissue macrophages remains to be determined.

Summary Indigenous people appear to have a greater pro-inflammatory physiology likely reflecting environmentalgene interactions (5,6,24). Due to the greater incidence of early onset metabolic disease in First Nations and other Indigenous populations, we were interested in determining the immune events associated with early onset T2D. Taken together, these initial findings suggest that certain immunological parameters are common in obese youth independent of T2D. PBMC-induced TNF-a synthesis, for example, did not differ between obese adolescents with and without T2D. However, it appears that in early onset T2D, there is a greater susceptibility to IL-1b synthesis upon exposure to low levels of LPS or the fatty acid palmitate. Thus, there may be no safe amount of certain lipid complexes for individuals with T2D to consume. We are continuing to evaluate systemic and cellular immunity in early onset T2D, in conjunction with age- and BMI-matched controls. T2D presents a serious burden to the First Nations community. The goal of our studies is an improved understanding of the biology behind T2D in First Nations children in support of new therapeutics in the prevention of T2D and related complications.

Conflict of interest and funding Authors have no conflict of interests to report. Authors would like to thank the Dr. Paul H.T. Thorlakson Foundation, University of Manitoba for funding this study.



References 1. Ley SH, Harris SB, Mamakeesick M, Noon T, Fiddler E, Gittelsohn J, et al. Metabolic syndrome and its components as predictors of incident type 2 diabetes mellitus in an Aboriginal community. CMAJ. 2009;180:61724. 2. Vanderloo SE, Johnson JA, Reimer K, McCrea P, Nuernberger K, Krueger H, et al. Validation of classification algorithms for childhood diabetes identified from administrative data. Pediatr Diabetes. 2012;13:22934. 3. Amed S, Dean HJ, Panagiotopoulos C, Sellers EA, Hadjiyannakis S, Laubscher TA, et al. Type 2 diabetes, medication-induced diabetes, and monogenic diabetes in Canadian children: a prospective national surveillance study. Diabetes Care. 2010;33:78691. 4. Sellers E, Dean H. Clinical and demographic characteristics of type 2 diabetes in youth at diagnosis in Manitoba and Northwestern Ontario (20062011). Can J Diab. 2012;36: 1148. 5. Aborsangaya KB, Dembinski I, Khatkar S, Alphonse MP, Nickerson P, Rempel JD. Impact of aboriginal ethnicity on HCV core-induced IL-10 synthesis: interaction with IL-10 gene polymorphisms. Hepatology. 2007;45:62330. 6. Rempel JD, Hawkins K, Lande E, Nickerson P. The potential influence of KIR cluster profiles on disease patterns of Canadian Aboriginals and other indigenous peoples of the Americas. Eur J Hum Genet. 2011;19:127680. 7. Shields M. Measured obesity: overweight Canadian children and adolescents. Statistics Canada. Cat. No. 82-6620MWE2005001. Anal Stud Rep. 2005;1:134. 8. Willows ND, Marshall D, Raine K, Ridley DC. Diabetes awareness and body size perceptions of Cree schoolchildren. Health Educ Res. 2009;24:10518. 9. Wahi G, Zorzi A, Macnab A, Panagiotopoulos C. Prevalence of type 2 diabetes, obesity and the metabolic syndrome among Canadian First Nations children in a remote Pacific coast community. Paediatr Child Health. 2009;14:7983. 10. Dean HJ, Young TK, Flett B, Wood-Steiman P. Screening for type-2 diabetes in aboriginal children in northern Canada. Lancet. 1998;352:15234. 11. Young TK, Dean HJ, Flett B, Wood-Steiman P. Childhood obesity in a population at high risk for type 2 diabetes. J Pediatr. 2000;136:3659. 12. Rabe K, Lehrke M, Parhofer KG, Broedl UC. Adipokines and insulin resistance. Mol Med. 2008;14:74151. 13. Mangge H, Schauenstein K, Stroedter L, Griesl A, Maerz W, Borkenstein M. Low grade inflammation in juvenile obesity and type 1 diabetes associated with early signs of atherosclerosis. Exp Clin Endocrinol Diabetes. 2004;112:37882. 14. Weisberg SP, McCann D, Desai M, Rosenbaum M, Leibel RL, Ferrante AW, Jr. Obesity is associated with macrophage accumulation in adipose tissue. J Clin Invest. 2003;112: 1796808. 15. Bertola A, Bonnafous S, Anty R, Patouraux S, Saint-Paul MC, Iannelli A, et al. Hepatic expression patterns of inflammatory and immune response genes associated with obesity and NASH in morbidly obese patients. PLoS One. 2010;5:e13577. 16. Dasu MR, Jialal I. Free fatty acids in the presence of high glucose amplify monocyte inflammation via toll-like receptors. Am J Physiol Endocrinol Metab. 2011;300:E14554. 17. Nieto-Vazquez I, Fernandez-Veledo S, Kramer DK, VilaBedmar R, Garcia-Guerra L, Lorenzo M. Insulin resistance associated to obesity: the link TNF-alpha. Arch Physiol Biochem. 2008;114:18394. 18. Vanderford NL. Defining the regulation of IL-1beta- and CHOP-mediated beta-cell apoptosis. Islets. 2010;2:3346.

19. Eder K, Baffy N, Falus A, Fulop AK. The major inflammatory mediator interleukin-6 and obesity. Inflamm Res. 2009;58: 72736. 20. Dasu MR, Devaraj S, Park S, Jialal I. Increased toll-like receptor (TLR) activation and TLR ligands in recently diagnosed type 2 diabetic subjects. Diabetes Care. 2010;33: 8618. 21. Shi H, Kokoeva MV, Inouye K, Tzameli I, Yin H, Flier JS. TLR4 links innate immunity and fatty acid-induced insulin resistance. J Clin Invest. 2006;116:301525. 22. Wong FS, Wen L. Toll-like receptors and diabetes. Ann NY Acad Sci. 2008;1150:12332. 23. Stringer DM, Sellers EA, Burr LL, Taylor CG. Altered plasma adipokines and markers of oxidative stress suggest increased risk of cardiovascular disease in First Nation youth with obesity or type 2 diabetes mellitus. Pediatr Diabetes. 2009;10: 26977. 24. Larcombe L, Rempel JD, Dembinski I, Tinckam K, Rigatto C, Nickerson P. Differential cytokine genotype frequencies among Canadian Aboriginal and Caucasian populations. Genes Immun. 2005;6:1404. 25. Dean HJ, Sellers EA. Comorbidities and microvascular complications of type 2 diabetes in children and adolescents. Pediatr Diabetes. 2007;8(Suppl 9):3541. 26. Chuback J, Embil JM, Sellers E, Trepman E, Cheang M, Dean H. Foot abnormalities in Canadian Aboriginal adolescents with type 2 diabetes. Diabet Med. 2007;24:74752. 27. Dart A, Sellers E, Brownell M, Rigatto C, Dean H, Martens P. High burden of renal complications in youth onset type 2 diabetes. Diabetes Care. 2012;35:126571. 28. Hegele RA, Cao H, Harris SB, Hanley AJ, Zinman B, Connelly PW. The private hepatocyte nuclear factor-1alpha G319S variant is associated with plasma lipoprotein variation in Canadian Oji-Cree. Arterioscler Thromb Vasc Biol. 2000; 20:21722. 29. Sellers EA, Triggs-Raine B, Rockman-Greenberg C, Dean HJ. The prevalence of the HNF-1alpha G319S mutation in Canadian aboriginal youth with type 2 diabetes. Diabetes Care. 2002;25:22026. 30. Troiano RP, Flegal KM. Overweight children and adolescents: description, epidemiology, and demographics. Pediatrics. 1998;101:497504. 31. Krueger C, Collister M, Minuk G, Janke A, Lerner J, Wong S, Rempel J. The interaction of obesity and HCV protein induced TNF-a in treatment outcomes for hepatitis C virus infection. Submitted. 32. Pyrzak B, Ruminska M, Popko K, Demkow U. Adiponectin as a biomarker of the metabolic syndrome in children and adolescents. Eur J Med Res. 2010;15(Suppl 2):14751. 33. Giordano P, Del Vecchio GC, Cecinati V, Delvecchio M, Altomare M, De Palma F, et al. Metabolic, inflammatory, endothelial and haemostatic markers in a group of Italian obese children and adolescents. Eur J Pediatr. 2011;170: 84550. 34. Kopp HP, Krzyzanowska K, Mohlig M, Spranger J, Pfeiffer AF, Schernthaner G. Effects of marked weight loss on plasma levels of adiponectin, markers of chronic subclinical inflammation and insulin resistance in morbidly obese women. Int J Obes (Lond). 2005;29:76671. 35. Moran O, Phillip M. Leptin: obesity, diabetes and other peripheral effects*a review. Pediatr Diabetes. 2003;4:1019. 36. Ley SH, Harris SB, Connelly PW, Mamakeesick M, Gittelsohn J, Hegele RA, et al. Adipokines and incident type 2 diabetes in an Aboriginal Canadian [corrected] population: the Sandy Lake Health and Diabetes Project. Diabetes Care. 2008;31: 14105.


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37. Popko K, Gorska E, Stelmaszczyk-Emmel A, Plywaczewski R, Stoklosa A, Gorecka D, et al. Proinflammatory cytokines Il-6 and TNF-alpha and the development of inflammation in obese subjects. Eur J Med Res. 2012;15(Suppl 2):1202. 38. Gonzalez M, Del Mar Bibiloni M, Pons A, Llompart I, Tur JA. Inflammatory markers and metabolic syndrome among adolescents. Eur J Clin Nutr. 2012;66:11415. 39. Zeyda M, Farmer D, Todoric J, Aszmann O, Speiser M, Gyori G, et al. Human adipose tissue macrophages are of an antiinflammatory phenotype but capable of excessive pro-inflammatory mediator production. Int J Obes (Lond). 2007;31: 14208. 40. Fogeda M, Gallart L, Gutierrez C, Vendrell J, Simon I, GarciaEspana A, et al. High expression of tumor necrosis factor alpha receptors in peripheral blood mononuclear cells of obese type 2 diabetic women. Eur Cytokine Netw. 2004;15:606. 41. Taube A, Schlich R, Sell H, Eckardt K, Eckel J. Inflammation and metabolic dysfunction: links to cardiovascular diseases. Am J Physiol Heart Circ Physiol. 2012;302:H214865. 42. Koleva-Georgieva DN, Sivkova NP, Terzieva D. Serum inflammatory cytokines IL-1beta, IL-6, TNF-alpha and VEGF have influence on the development of diabetic retinopathy. Folia Med (Plovdiv). 2011;53:4450.

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43. Dinarello CA. A clinical perspective of IL-1beta as the gatekeeper of inflammation. Eur J Immunol. 2011;41:120317. 44. De Nardo D, Latz E. NLRP3 inflammasomes link inflammation and metabolic disease. Trends Immunol. 2011;32:3739. 45. Stienstra R, Tack CJ, Kanneganti TD, Joosten LA, Netea MG. The inflammasome puts obesity in the danger zone. Cell Metab. 2012;15:108. 46. Larsen CM, Faulenbach M, Vaag A, Volund A, Ehses JA, Seifert B, et al. Interleukin-1-receptor antagonist in type 2 diabetes mellitus. N Engl J Med. 2007;356:151726. 47. Ehses JA, Lacraz G, Giroix MH, Schmidlin F, Coulaud J, Kassis N, et al. IL-1 antagonism reduces hyperglycemia and tissue inflammation in the type 2 diabetic GK rat. Proc Natl Acad Sci USA. 2009;106:139984003. *Julia D. Rempel 804D JBRC 715 McDermot Ave R3E 3P4, Winnipeg, MB Canada Tel: 204-789-3825 Email: [email protected]


CHRONIC DISEASE æ

The peculiarities of food allergies in accordance with the level of injury of respiratory tract in children of Eastern Siberia Irina V. Borisova* and Svetlana V. Smirnova Federal State Budget Institution, Scientific Research Institute for Medical Problems of the North, Siberian Division of Russian Academy of Medical Sciences, Krasnoyarsk, Russia

Aim. To determine the course of food allergy in accordance with the level of respiratory tract injury in children of Eastern Siberia. Design of the research. We have examined 70 children aged 216, who have food sensibilization. We divided them into 2 groups: group I (n 32) with diseases of the upper and middle respiratory tract; and group II (n 38) with diseases of the lower respiratory tract. Methods. Allergological medical history, clinical laboratory examination and immunological examination, including the determination of IgA, IgM, IgG and IgE in blood serum. In cases where causal allergens were found, elimination diets were recommended. Results. Onset of upper respiratory tract injury in group I was more often registered in children aged 01; in group II, it was in the 37 age group. Isolated food sensibilization was more often marked in group I as compared to group II. Atopic mechanisms of respiratory tract injuries were more often registered in group II children. In the course of the elimination diet, we marked positive dynamics in 100% of group I and in 75% of group II. Conclusion. The most frequent allergens that cause respiratory forms of food allergy are hen eggs, cow milk, nutritive cereals, vegetables and fruit. Indices of a humoral link of immunity in the examined patients were more often registered as normal or their level is increased. Timely etiotropic therapy in the majority of cases allows for a stabilization of allergic inflammation. Keywords: food allergy; respiratory tract; elimination diet

he diseases of respiratory tract are still the leaders in the structure of morbidity and mortality, which causes medical and social importance of this problem. Children are the first to be recognized as a high-risk group, namely those with pathological processes in the respiratory tract. The reasons for a relapse of pathological processes in the respiratory system can be due to chronic inflammatory diseases, transitory age peculiarities of the immune system and other pathological processes of acquired or congenital genesis (1). In some cases, respiratory organs become ‘‘shocking’’ for the development of allergic inflammation. Food products provide humans with the first and the most important antigen exposure. That is why in children food allergy is one of the earliest and most frequent reasons of the formation of pathological process. Going forward, it determines the tempo of their development and the

T

location of allergic inflammation (reactive factor). The question of the frequency of respiratory symptoms in food allergy is still wide open, because data on this research is minimal and it is sometimes contradictory. According to some authors, food sensibilization is present in 625% in children with respiratory diseases. Others say it is in 80% of cases (2,3). Respiratory signs of a food allergy can be found in the upper and lower respiratory tract. With this in mind, the course of the food allergy can be taken from different nosological forms (rhinitis, sinusitis, tracheitis, bronchitis, etc.), and is in many cases not recognized as a cause of the disease. This results in therapy for recurrent pathological processes in the respiratory tract with antibacterial, antivirus preparations being inefficient. A food allergy, which is diagnosed on time, leads to the formation of a severe, constantly relapsing course of the disease, and the


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involvement of other organs and systems into the pathology process. According to some authors, the food allergy is ‘‘starting’’ sensibilization here in many cases. Based on its background, the spectrum of sensibilization to allergens of different groups is broadening (pollen, domestic) with ageing. Other authors believe it has the same meaning as aspiration allergy or sometimes it is more significant (4,5). Therefore, inconsistencies in published data necessitate further research in this sphere. The aim of our research is to determine risk factors in food allergy development, identify the characteristics of its etiologic structure, clinical immunological signs and the efficiency of elimination diet therapy in children with the diseases of upper and lower respiratory tract.

The research was carried out by standard clinical laboratory techniques, including medical history (onset of the disease, frequency, character of clinical signs) and results of laboratory tests. All children passed an immunological examination. The concentration of common immune globulins (A, M, G) in blood serum was estimated by G. Manchini radial immunodiffusion technique and the content of common IgE by immune enzyme analysis. The food allergy was diagnosed after complex clinical laboratory examination of the patients taking into account the data of medical history, skin tests with food, domestic, pollen allergens, elimination and provocation tests. In cases when cause allergens were found, individual elimination diets were introduced. Their efficiency was evaluated by the dynamics of clinical signs and common conditions of a child. The duration of patient supervision in the course of diet therapy was 612 months. The results were regarded as excellent, when clinical symptoms disappeared; good, when the symptoms considerably decreased; and satisfactory, when there were mild improvements in clinical signs. Data processing was carried out using applied programs «Statistica 6.0».

Materials and methods We have examined 70 children aged 216. Among them, 76% were in pre-school and 24% were older than 7 years. We defined 2 groups. Group I (n 32) with diseases of the upper and middle respiratory tract (rhinitis, adenoiditis and tracheitis). They belonged to the category ‘‘frequently and chronically ill children’’ (frequent respiratory diseases in medical history). Group II (n 38) with diseases of the lower respiratory tract (bronchial asthma). The main criteria for subjects to be involved in the research included 1) the presence of food sensibilization; 2) Group I: acute diseases of upper respiratory tract with a frequency higher than 6 times a year, the duration of the diseases over 6 months; 3) Group II: ‘‘Bronchial asthma’’. In bronchial asthma, the course of the disease was registered as mild in 74% and severe in 26% of cases. In group I, the symptoms of respiratory diseases (sneezing, nasal blockage, coughing and/or temperature) were marked monthly in 63% of cases, and 67 times a year in 37% of cases. In group II, disease exacerbation in 53% was registered no more than 6 times per year; in 29% of cases, 23 times a week; and in 18% of cases, 23 times a month.

Results In the development of a food allergy, genetics play a considerable role. Having analyzed risk factors in the formation of a food allergy, among them the first place belongs to atopia tainted heredity, we marked that in 69% of the examined children where their parents or relatives suffered from different allergy diseases. In group I, the frequency of hereditary taint was registered more often (80%) than in group II (58%). The nature of infant feeding and the duration of breast-feeding are extremely important in allergy development. The analysis of the data showed that even though breast feeding duration was 1 year in most children within both groups, the duration of breast-feeding was up to 3 months of age in every third child in group II (Table I). It appears to be the

Table I. Duration of breast feeding in infants and time period of first manifestation of symptoms of respiratory tract disturbances in children (%) Ages

03 months

Group I (n32) Duration of breast feeding in infants 0

Group II (n38)

33

06 months

43

0

012 months

41

7

Over 12 months

16

0

Time period of first manifestation of symptoms of respiratory tract disturbances Earlier than 1 year

40

13 years

35.5

47 years Senior than 8 years

13.5 1

302

17, p B0.01 33 42, p B0.001 8


The peculiarities of food allergy

Table II. Frequency of the changes in the indices of immunity humoral link in children with respiratory forms of food allergy (%) Hyperproduction of

Transitory

immunoglobulins Immuno globulins

Norm indices

Group I (n32)

Group II (n38) 43, p B0.001

IgA

20

IgM IgG

45 50

IgE

32

hypogammaglobulinemia

Group I (n 32)

Group II (n38)

Group I (n32)

Group II (n38)

43

23, p B0.01

34

30

18 18

23 23

53 37 53, p B0.01

leading risk factor in the development of severe forms of food allergies in children, bronchial asthma in particular. When studying allergological medical history, we revealed that the first symptoms of allergy, such as skin signs were registered in early ages in 42.5% of cases. True differences between groups I and II had not been marked. Furthermore, the percentage of this or that food intolerance in group I tended to decrease (39%) with growing-up as distinguished from group II (58%). Having analyzed the time when the first symptoms of respiratory tract disturbances appear, we marked some differences between the groups (Table I). In group I, the onset of respiratory tract disorders was registered earlier than age 1 year and there was a gradual decline with growing-up. On the contrary in group II, the percentage of lower respiratory tract disorders increased with growing-up and bronchial asthma morbidity peak relates at ages 37. It is known that in food sensibilization, the allergic disorders of respiratory tract can be isolated and also they can be accompanied by disturbances to other organs. In such cases, a system allergy disease is being formed: dermatologic gastrointestinal, respiratory intestinal syndromes, atopic disease. In 83% of the cases in group I, we found comorbid complaints related to other organs in anamnesis vitae: 55% of the children complained of frequent nasal blockage, 34% had stomach pain after meals, 10% had a poor appetite and stool problems. In group II, comorbid complaints were less frequent (67%): 58% complained of frequent nasal blockage, 33% had rhinitis, 17% had headaches and 8% suffered from stomach pain after meals. Beside hereditary traits, the sensibilization of organisms is critical to food allergy development. The results of skin tests are definitely interesting. In group I, we marked isolated food sensibilization in 36% of cases, and polyvalent (domestic, pollen) in 64% of cases. In group II, in the majority of cases (92%), we had marked polyvalent sensibilization. In group I, skin tests showed the following foods in the structure of etiologic factors: hen egg, 80%; cow milk, 62%; chicken, 56%; wheat flour, cereals (peeled barley, ground oat, buckwheat), 50%; fish, 49%; citrus, 44% cases. In group II, we had marked: hen egg, 73%; cow milk, 68%; cereals, 48%; vegetables and fruits,

37 32

23 40

68

47, p B0.01

47%; citrus, 36%; fish, 11% cases. The sensibilization to 4 and more foodstuffs was typical in both groups in the majority of cases (83%) and only in 17% it was found in regard to 13 foodstuffs. Taking into account that the said foodstuffs are consumed daily, it is not possible to state clear dependence between their consumption and exacerbations (after anamnesis data). With this in mind, a food allergy was confirmed by elimination and provocation tests in each case. In group I, the exacerbation of respiratory symptoms was caused by hen egg in 82%, cow milk in 64%, wheat flour in 55%, vegetables and fruits in 14% and fish in 9% of cases. In group II, the exacerbation of bronchial asthma was caused by hen egg in 90% of cases, cow milk in 76%, vegetables and fruits in 52%, wheat flour in 48%, meat in 14%, and nut and fish in 9% of cases. Clinical characteristic of respiratory signs of food allergies is all-seasonal course of the disease in the majority of cases (72% in group I and 100% in group II) and gradual start of the disease. A clinical picture of a bronchial asthma attack was characterized by a preattack period in all of the children. Its duration was shorter in patients with an allergy to fish, nuts, citrus as compared to subjects with an allergy to milk, eggs, cereals, vegetables, and fruits. In 64% of group I, we marked the clinical symptoms, which lasted over 3 weeks, of the inefficiency of traditional methods of acute respiratory disease treatment. In bronchial asthma (group II) under associated domestic sensibilization, the disease was losing its typical dependence from the consumption of any food; the torpidity was stated in the course of the disease, which made it difficult to define the diagnosis. In comorbid pollen sensibilization, we found the seasonality in the formation of clinical symptoms of food allergy as a response to consumption of some allergy-causing food. Predominance (45%) of daynight coughing was typical in both groups; in 30% we marked night coughing; also in half of the patients coughing showed a non-productive character within the whole period of the disease. When studying the humoral link of the immunity, we found that in subjects with respiratory signs of a food allergy that the indices of IgA, IgM, IgG are more often registered within the norm or their increased level had


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been marked (Table II). Only in 34% of cases did we reveal ‘‘transitory hypogammaglobulinemia of infancy’’ and we did not mark any true differences between groups. We marked insufficient level of IgA in the most cases. Its deficiency is known to be an unfavorable factor in the development of a food allergy. It is well-known that the main immunological mechanism of a food allergy is the 1st type of tissue injury (reaginic). This mechanism is mediated by antibodies related to immune globulins of IgE and IgG4 class. Our research showed the increase of common IgE level in group I only in 32% cases and in Group II in 53% cases. This can prove that, with the exception of IgE-mediated mechanisms, the leading role in food allergy pathogenesis belongs to IgG4 class reagines, which are known to be less aggressive than IgE and so they, to a lesser extent, disturb the respiratory system in patients with an upper respiratory tract disorder. Etiotropic therapy was prescribed for children with ‘‘food allergy’’ diagnosis (individual elimination diets) and other kinds of therapy due to the status of the patient (26% of bronchial asthma), among them stabilizers of membranes of mast cells, anti-inflammatory preparations Intal, Tilade. The period of diet therapy in most cases lasted 6 months (91%) and in 9% of cases, 12 months. In the course of elimination diet therapy, we marked positive dynamics in clinical signs in group I in 100% of cases and in group II in 75% of cases on average on days 45 of dieting. At later stages, group I showed excellent results in 60% of cases and good results in 40% (we marked the decrease of exacerbation number to 23 times per year). In group II, stabilizing of the allergy process in further time periods was registered only in 56% of cases. This data confirms a high meaning of the influence of broadening sensibilization spectrum (mostly on the account of aspiration allergens pollen and domestic) upon the efficiency of the elimination diet therapy.

Conclusion In food sensibilization, the disorders of the respiratory tract are possible at any level, which is why clinical signs

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of food allergy show significant diversity. In the structure of etiological factors of the development of respiratory forms in food allergy, the most frequent are hen egg, cow milk, cereals, vegetables and fruits. In children with respiratory signs of a food allergy, the indices of a humoral link of immunity in most cases are registered within the norm and demonstrate increased levels. Timely conducted etiotropic therapy in most cases allows us, within a short period of time, to achieve stabilization of allergic inflammation, to decrease the frequency of retrocession, and to prevent progression of the disease under different signs including respiratory ones.


References 1. Markova TP, Chuvirov DG. Chronically and frequently ill children. Russ Med J. 2002;10:125. 2. Sampson H, Mendelson LM, Rosen JP. Fatal and near-fatal anaphylactic reactions to food in children and adolescents. N Engl J Med. 1992;327:3804. 3. Penard-Morand C, Charpin D, Raherison C, Kopferschmitt C. Long-term exposure to background air pollution related to respiratory and allergic health in schoolchildren. Clin Exp Allergy. 2005;35:127987. 4. Vorontzov IM, Matalygina OA. Clinical immunologic parallels in diseases associated with food sensibilization. Pediatrics. 1981;4:4851. 5. Ferguson A, Barnetson R. Alternative treatment of food intolerance and allergy. Ghem and Ind. 1984;3:1003. *Irina V. Borisova Federal State Budget Institution, Scientific Research Institute for Medical Problems of the North Siberian Division of Russian Academy of Medical Sciences P. Zheleznyaka Str., 3 G. Krasnoyarsk 660022 Russia Tel: 73912280683 Fax: 73912280681 Email: [email protected]


CHRONIC DISEASE æ

The influence of social support on risk of acute cardiovascular diseases in female population aged 2564 in Russia Valery V. Gafarov1,2*, Dmitry O. Panov1,2, Elena A. Gromova1,2, Igor V. Gagulin1,2 and Almira V. Gafarova1,2 1

Laboratory of Psychological and Sociological Issues of Internal Medicine, Institute of Internal Medicine, Siberian Branch of the Russian Academy of Medical Sciences, Novosibirsk, Russia; 2Collaborative Laboratory of Epidemiology Cardiovascular Diseases, Siberian Branch of the Russian Academy of Medical Sciences, Novosibirsk, Russia

Objective. To study the prevalence of social support (SS) and its influence on the relative risk (RR) of myocardial infarction (MI) and stroke in the female population aged 2564 in Russia. Materials and methods. Under the third screening of the WHO ‘‘MONICA-psychosocial’’ programme, a random representative sample of women aged 2564 (n 870) were surveyed in Novosibirsk. SS was measured according to the methods of the BerkmanSym test [indices of close contacts (ICC) and index of social network (SNI)]. From 1995 to 2010, women were followed for 16 years to observe the incidence of MI and stroke. Results. The prevalence of low levels of ICC and SNI in women aged 2564 was 57.1 and 77.7%, respectively. Low levels of ICC and SNI were associated with poor self-rated health and awareness about their health, adverse behavioral habits, high job strain and family stress. Rates of MI and stroke development were higher in married women with low ICC and SNI who were being in class ‘‘hard manual work’’. Over a 16-year study period, the RR of MI in women with low ICC compared to those with high ICC was 4.9 times higher, and the risk of stroke was 4.1 times higher. Low level of SNI increased MI risk in 2.9 times, risk of stroke in 2.7 times. Conclusions. Majority of women aged 2564 years in Russia have low social support which is associated with poor self-rated health, low awareness about the health that increases the risk of MI and stroke in 2.74.9 times in groups of ‘‘married’’ and ‘‘hard physical work’’. Keywords: social support; self-rated health; awareness; relative risk; myocardial infarction; stroke

ecent studies have shown that low social support (SS) in the general population is more common in women than in men, and a small index of social network (SNI) in women is associated with coronary heart disease risk factors and coronary artery stenosis (1,2). Social isolation is associated with increased cardiovascular morbidity and all-cause mortality (36). Women are more likely to need social affiliation than men, with social deprivation and loss of SS being associated with greater sclerosis of coronary vessels for them (79). The absence of such surveys in Russia necessitated a study on the prevalence and influence of SS (low levels of close contacts and SNI) on the relative risk (RR) of myocardial infarction (MI) and stroke over a period of 16 years, focussing on the relationship between SS and awareness, and attitude to health in the female population aged 2564 in Russia/Western Siberia (Novosibirsk).

R

Materials and methods Within the framework of the third screening (1994) of the WHO programme ‘‘Multinational Monitoring of Trends and Determinants of Cardiovascular Disease’’ (MONICA) and sub-programme ‘‘MONICA-psychosocial (MOPSY)’’ (10), a random representative sample of women aged 2564 (n870) from one of Novosibirsk’s districts were surveyed. The representative sample was generated on the basis of the electoral lists of citizens using a table of random numbers. The response was 72.5%. This survey was performed using the standard methods accepted in the ‘‘MONICA study’’ protocol. The programme of psycho-social screening examinations includes registering of social characteristics such as marital status, level of degree, professional class and psychosocial tests. SS was investigated at the baseline examination using a BerkmanSym test (11); an index of close contacts (ICC)


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and index of SNI were measured. ICC level was assessed as high, average, low; SNI-high, average-1, average-2, low. Questionnaire entitled ‘‘Awareness and attitude towards the health’’ was used for assessment. It covered attitude towards health and cardiovascular diseases (CVD) prevention; attitude towards smoking, diet and physical training; job and family stress. Over a follow-up period (19952010), there were 35 cases (6.3%) of stroke incidence which were registered by means of examination, analysis of medical histories, cards and death certificates. A total of 15 cases (2.7%) of MI were revealed in the studied cohort using the WHO programme ‘‘Registry of Myocardial Infarction’’ data (12). Statistical processing was fulfilled by means of programme pack SPSS version 11.5. Cox-proportional regression model was used to estimate RR, taking into account different time intervals. Persons having baseline MI, and a history of stroke or heart disease and diabetes mellitus were excluded from analysis. The Chi-square test was used to test the statistical significance of differences between groups (x2). Values of p B0.05 were considered statistically significant.

Results ICC levels in the female population aged 2564 in 1994 were: a low level of index close contacts 57.1%, average ICC 37.3%, high 5.7%. Prevalence of low levels of SNI (combined SNI-low, SNI-average 1) was 77.7%, SNI-average 219.8%, SNI-high 2.5%. There was a substantial growth of negative selfassessments health as ‘‘ill’’ and there was a reducing in assessments as ‘‘healthy’’ in women with low ICC (ICClow 14.5% and 11.2%; ICC-high 7.1% and 17.9%, respectively); no differences were found for SNI index towards self-rated health. The trend of increasing complaints about health was evident in those with lowest SS (ICC-low 90.1%; SNI-low 90.3%). In conditions of low SS, women believe that taking care of their health is not enough (x2 19.37, df6, p B0.01) and note the high ‘‘probability to be ill in the next 510 years’’ (ICClow 59.2%, x2 12.23, df 4, p B0.05; SNI-low 57.4%, x2 20.11, df 6, p B0.01). Women with low ICC and SNI are more likely to stop working and seek medical help when they feel bad at work (x2 12.76, df6, p B0.05). However, 44% of those with low SNI do not consider influenza or febrility as a barrier and continue to work. The following tendencies are likely in women with low ICC and SNI with regard to job stress: they are less likely to change their specialty, perform less additional tasks, dislike their work, assess their responsibility as ‘‘insignificant’’ and have less opportunity to relax after a typical working day. There was a drop in their capacity to work during the current year (x2 17.43, df 9, p B0.05).

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With increasing levels of S, there was stability in their marital status (ICC-low 17.9%, ICC-high 3.7%; SNIlow 15.8%, SNI-high 0%); conflicts in the family were on the rise (ICC-low 55.6%, ICC-high 67.9%, x2 13.66, df6, pB0.05; SNI-low 57.3%, SNI-high 78.6%; p 0.05). With regard to smoking, women with low ICC and SNI have reduced motivation cut down smoking (answer ‘‘smoked less than a year ago’’: ICC-low 19.8%, ICChigh 28.6%; SNI-low 25%, SNI-high 100%); they also try to follow a diet plan (ICC-low 23%, ICC-high 29.6%; SNI-low 21.4%, SNI-high 42.9%). But, such persons are 3 times less likely to respond that ‘‘do physical exercises regularly’’; it is associated with a decline in the proportion of people spending their leisure productively (ICC-low 19.9%, ICC-high 35.6%, p 0.05; SNI-low 23.6%, SNI-high 28.6%, x2 16.93, df6, p B0.05). The structure of marital status in a cohort of women with MI and low SS was as follows: married 66.6 and 57.1%; divorced 16.7 and 28.6%; widowed 16.7 and 14.3% for low ICC and SNI, respectively. There were no unmarried women. There was a tendency of increased MI incidence in married women with low ICC and SNI indices compared to higher levels of SS. The structure of marital status in a cohort of women with stroke and low SS was: never been married 15.8 and 13%; married 78.9 and 73.9%; divorced 5.3 and 8.7%; widowed 0 and 4.3% for low ICC and SNI, respectively. The incidence of stroke among married women with low ICC was higher in comparison with higher ICC (x2 3.95, df1, p B0.05). There was a tendency towards higher stroke incidence in married women with low SNI. The educational level of persons with stroke and low ICC was: higher education (university) 40%; incomplete higher/vocational education 40%; elementary school 20%. The share of women with MI and low SNI was equally distributed among the different grades of education 33.3%. Women with higher and vocational education and low ICC are more likely to have higher rates of MI. The structure of education in women with developed stroke and low ICC was as follows: higher education 10.5 and 13%; incomplete higher/vocational education 36.8 and 43.5%; high school 31.6 and 26.1%; elementary school 21.1 and 17.4% for low ICC and SNI, respectively. There was a tendency towards higher stroke rates in those with incomplete higher/vocational education and low ICC/SNI. Professional status in women with MI and low ICC was presented in the following categories: 40% heads, 20% engineers, 40% pensioners. In comparison, the structure in women with MI and low SNI had several differences: 33.3% heads, 16.7% engineers, 50% pensioners. There was a tendency towards an increase of


The influence of social support on CVD risk

MI incidence in women who were a ‘‘head’’ having low ICC and SNI compared to high SS levels. Professional status in women with stroke and low ICC was: 5.3% middle executives, 15.8% heads (managers), 10.5% engineers, 15.8% working hard and light physical labour, 21.1% moderate physical labour, 5.3% pensioners, 10.5% military servants. The structure of professional status in group with developed stroke and low SNI was: 8.7% middle executives, managers, engineers and working hard and light physical labour had an equal share to 13%, 21.7% moderate physical labour, pensioners and military servants were equal shares 8.7%. The rate of stroke incidence in people engaged in hard physical labour with low ICC was higher than in engineers (x2 6.16, df 1, p B0.05) and pensioners (x2 12.99, df1, p B0.001) with low ICC. A significant increase in the rate of stroke was found in people engaged in severe physical labour with low SNI compared to pensioners with low SNI (x2 7.72, df1, p B0.01). RR of MI in women aged 2564 with a low ICC was 4.9 times higher (95% CI 1.10821.762; p B0.05) compared to those with higher ICC levels; it was 4.1 times higher for stroke (95% CI 1.19314.055; p B0.05) than in those with a higher level of ICC over the 16 years. Women with low SNI aged 2564 had a 2.92-fold risk of MI incidence (95% CI 1.0408.208; p B0.05) and a 2.72-fold risk of stroke (95% CI 1.0946.763; p B0.05) compared to persons with a higher level of SNI. The risk of MI was substantially increased in the 5564 age group and it was 5.9 times higher (95% CI 1.53422.947; p 0.01) for women with lower SNI.

Discussion Our studies showed that self-rated health has deteriorated among the female population and that the number of health complaints has increased with decreasing SS. There is a lack of awareness of the female population about their health, which is consistent with other studies (13,14). Awareness about health is known to be related to the frequency of contact with family, friends and near and dear ones (15). High levels of job and family stress were identified in women with low ICC and SNI levels. It is known that family stress in women of working age with ischemic heart disease affects their SNI, that is, it reduces social integration, sense of affiliation and tangible support (16). In our study, low levels of ICC and SNI are associated with negative behavioral habits and the lack of any changes (low smoking cessation, physical activity, adherence to diet) are confirmed by other researchers (17). There is a necessity for well-developed SNI, which comes from the fact that high levels of SS can reduce the impact of negative effects and psycho-social factors on adverse lifestyle (smoking, alcohol, poor diet) (18).

Our findings show a significant effect of low levels of SS on the relative risk of MI and stroke in the female population of working age in Russia/Siberia. These data are confirmed by other longitudinal studies where low SS is a predictor of morbidity and mortality from acute CVD (1921). Based on our results, we observed that married women with low ICC and SNI indices are more likely to develop stroke and there is a tendency towards an increased MI incidence rate. This is probably due to higher levels of family stress in this group compared to the divorced and widowed group, and this is the confirmed opinion of other authors (22,23). There was a significant increase in the incidence rate of stroke in the hard physical labour group in women with low levels of ICC and SNI. There is a tendency for an elevated MI incidence rate in women-executives (managers). The presence of intrapersonal conflict (family or career) and high levels of stress and job strain as shown in other studies is associated with a higher incidence of CVD in this group of women (24,25).

Conclusions a. Prevalence of low levels of SS (ICC and SNI) in female population aged 2564 in Russia/Siberia is high, 57.1 and 77.7%, respectively. b. Low levels of SS (ICC and SNI) associated with poor self-rated health, low level of awareness about the health, adverse behavioral habits in the female population aged 2564 in Russia/Siberia. c. Over 16-year study period in the female population aged 2564 in Russia/Siberia, low levels of SS (ICC and SNI) significantly increased the relative risk of MI and stroke, especially in the older age group. d. Low levels of SS (ICC and SNI) which lead to the development of MI and stroke in Russian (Siberian) women aged 2564 associated with marital status ‘‘married’’; average levels of a degree; professional status ‘‘the head’’, ‘‘physical labourer’’; high levels of family and job stress.


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17. Piwonski J, Piwonska A, Drygas W. Do negative psychosocial risk factors influence the person’s behaviour to more unhealthy? The results of national multicenter health survey (WOBASZ). Eur Heart J. 2009;30(Abstract Suppl):521. 18. Allen J, Markovitz J, Jacobs DR Jr., Knox SS. Social support and health behavior in hostile black and white men and women in CARDIA. Coronary artery risk development in young adults. Psychosom Med. 2001;63:60918. 19. Vogt TM, Mullooly JP, Ernst D, Pope CR, Hollis JF. Social networks as predictors of ischemic heart disease, cancer, stroke and hypertension: incidence, survival and mortality. J Clin Epidemiol. 1992;45:65966. 20. Kaplan GA, Salonen JT, Cohen RD, Brand RJ, Syme SL, Puska P, et al. Social connections and mortality from all causes and from cardiovascular disease: prospective evidence from eastern Finland. Am J Epidemiol. 1988;128:37080. 21. House JS, Robbins C, Metzner HL. The association of social relationships and activities with mortality: prospective evidence from the Tecumseh community health study. Am J Epidemiol. 1982;116:12340. 22. Petersen H, Boysen G, Prescott E. Major life events and the risk of cardiovascular disease: findings from Copenhagen city heart study. EuroPRevent. 2008;(Abstract Details):145. 23. Peterson H, Prescott E. Social network and the risk of stroke: findings from the Copenhagen city heart study. EuroPRevent. 2009(Abstract Details);P103:34. 24. Gafarov VV, Panov DO, Gromova EA, Gagulin IV. Association of personal anxiety with others psychosocial factors in female population aged 2564 (epidemiological study based on the MONICA-psychosocial study), SMJ. Tomsk. 2011;26: 15661. 25. Hammar N, Alfredsson L, Johnson J. Job strain, social support at work, and incidence of myocardial infarction. Occup Environ Med. 1998;55:54853. *Valery V. Gafarov Laboratory of Psychological and Sociological Issues of Internal Medicine, Institute of Internal Medicine Collaborative Laboratory of Epidemiology Cardiovascular Diseases Siberian Branch of the Russian Academy of Medical Sciences B.Bogatkova 175/1 630089 Novosibirsk Russian Federation Russia Tel: 79231735863 Phone: 7-913-892-0003 Email: [email protected]


CHRONIC DISEASE æ

Evaluation of serum procathepsin B, cystatin B and cystatin C as possible biomarkers of ovarian cancer Elena A. Gashenko1,2, Valentina A. Lebedeva3, Ivan V. Brak1, Elena A. Tsykalenko4, Galina V. Vinokurova2 and Tatyana A. Korolenko1* 1

Institute of Physiology SB RAMS, Novosibirsk, Russia; 2Municipal Hospital N 3, Novosibirsk, Russia; Department of Oncology, Novosibirsk Medical University, Novosibirsk, Russia; 4Regional Diagnostic Center, Novosibirsk, Russia 3

Objectives. To evaluate procathepsin B, as well as endogenous inhibitors of cysteine proteases (cystatin B and cystatin C) in biological fluids as possible biomarkers of ovarian cancer. To observe levels of serum procathepsin B in different age groups. Study design. The sample (N 27) of women with gynaecological tumours included 18 patients with ovarian cancer (n 18) and 9 patients with benign ovarian tumours (n 9); 72 healthy women were in the control group. All patients were treated in Novosibirsk Regional Oncological Center, Russia. Serum samples of healthy women (n 40) aged 1870 years were used as controls for common biomarker of ovarian cancer CA125. In the Procathepsin B study, serum samples of healthy women (n 32) aged 1840 years (n 14), 4155 years (n 10) and 5680 (n 8) years were used as controls. Methods. Common biomarker of ovarian cancer, CA-125, was assayed by using a commercial kit (Vector, Koltsovo, Novosibirsk Region, Russia). Procathepsin B was measured by means of a commercial kit for human procathepsin B (R&D, USA); cystatin C was measured by commercial ELISA kits for human (BioVendor, Czechia); cystatin B was measured by ELISA kits for human (USCN Life Science Inc., Wuhan, China). Statistical analysis was performed by one-way ANOVA (Statistica 10 Program). Results. In the control group, serum procathepsin B concentration did not reveal age dependency. In the ovarian cancer group, both levels of serum procathepsin B and standard biomarker CA-125 increased significantly (both pB0.001) compared with the control group. In the benign ovarian tumour group, serum procathepsin B (pB0.001) and CA-125 (p 0.004) increased about 2.5- and 8-fold compared to the control group. Serum cystatin B level increased up to 1.7-fold in the ovarian cancer group compared to the control group. The increase of serum CA-125 was about 3.5-fold higher (p0.017) and procathepsin B was 1.8-fold higher (p B0.05) in the ovarian cancer group compared to the benign tumour group. Cystatin B in ascites fluid increased equally in both ovarian cancer (p B0.001) and benign ovarian tumours group (p B0.05). Cystatin C concentration in ascites fluid increased only in patients with ovarian cancer (p B0.05) and did not change in the benign tumours group. Large increases of procathepsin B level (about 13-fold, pB0.001) and to a lesser degree of cystatin C (1.8-fold, pB0.05) and cystatin B levels (1.4 fold, p B0.001) were revealed in ascites fluids of patients with ovarian cancer compared to the control serum. The significant difference in serum procathepsin B levels was noted between the ovarian cancer and benign tumour groups (p B0.05), which could be used in differential diagnostics between malignant and benign gynaecological tumours. Conclusion. Serum procathepsin B demonstrated significant promise as a new biomarker of ovarian cancer. Keywords: ovarian cancer; procathepsin B; cystatin B; cystatin C; biomarkers

varian carcinogenesis remains a research challenge due to many unknown factors involved in the malignant transformation sequences (1,2). Tumour cells were able to secrete both mature and proforms of proteases, and their inhibitors (to protect

O

themselves from proteolysis) (3,4). Proteases of different classes (cysteine, serine, aspartate and matrix metalloproteases) were universally involved in tumour development (5). Cysteine proteases (cathepsins B, L, H, K, S) and their endogenous inhibitors, cystatins, had been


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shown to play an important role both in tumour growth and metastases (6,7). CA-125, cancer antigen 125, was known as a protein that was found at high levels in most ovarian cancer cells. However, CA-125 was also elevated in several benign tumours. Procathepsin B was a pro-form of active mature form of cathepsin B (8,9) and could be suggested as a new tumour biomarker in ovarian cancer. Cystatin C and cystatin B, endogenous inhibitors of cysteine proteases, possibly were involved in tumour growth and cell proliferation (6,10). Cystatin B was thought to play a role in protecting against the cysteine proteases ‘‘leaking’’ from lysosomes (11) and was related to the prognosis of colorectal cancer (12,13), while cystatin C was involved in the regulation of cell proliferation, differentiation and migration (14). However, until now the role of cystatins B and C in human pathology, especially in oncology, had not been well understood. Searching for new tumour biomarkers among mature forms of proteases, their enzymatically inactive proforms and endogenous inhibitors of proteases is an important step in cancer diagnostics.

Materials and methods Study design All participants were divided into the following groups: ovarian cancer (n 18), benign tumours (n9), which included serous cystadenoma, mucinous cystadenoma and dermoid cyst) and a control group (n72). All patients were treated at Novosibirsk Regional Oncological Center (Department of Oncological Gynecology and Department of Mammology). Informed consent of patients was obtained in all cases; the Ethical Committee of the Institute of Physiology of SB RAMS approved the research. In procathepsin B study, serum samples of healthy women (n 32) aged 1840 years (n14), 41 55 years (n 10) and 5680 (n8) years were used as controls. Serum samples of healthy women (n40) aged 1870 years were used as controls for common biomarkers of ovarian cancer CA-125. Serum and ascetic fluids of women with tumours of the reproductive system (aged 1880 years) before operation were used for assay of procathepsin B, cysteine protease inhibitors and CA-125. Serum was obtained after centrifugation of blood samples at 3,000 g for 20 min at 48C (Eppendorf centrifuge 5415R, Hamburg, Germany) and stored at 708C until analysis. Ascetic fluid was obtained by syringe before surgery. CA-125 (CA-125-Immynoassay-Best kit, Vector, Koltzovo, Novosibirsk Region, Russia) was measured by Bio-Rad photometer, Model 68. Procathepsin B concentration in serum and ascetic fluid was measured by ELISA kits (R&D) for quantita-

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tive assay of human procathepsin B; cystatin B concentration was measured using ELISA kits for quantitative assay of human cystatin B level (USCN, Life Science Inc., China); and finally, cystatin C concentration was measured using ELISA kits for quantitative assay of human cystatin C (BioVendor, Czech Republic). Human procathepsin B immunoassay, a solid phase of ELISA, was designed to measure the pro-form of cathepsin B in different biological fluids. The minimum detectable dose of pro-cathepsin B ranged from 0.003 to 0.079 ng/ml. Human Cystatin B. ELISA kit for assay of human cystatin B (with detection range 31.22,000 pg/ml and sensitivity 12.6 pg/ml was used. Human Cystatin C. ELISA kit for human cystatin C with detection range 0.3121,000 ng/ml and sensitivity 10 pg/ml was used. Statistical analysis was performed by one-way ANOVA using Statistica 10 Program and Student t-test; the data were presented as mean9SEM; the difference was significant at p B0.05.

Results The results showed the following: the increase of procathepsin B concentration in ascites of patients with ovarian cancer was the highest compared to the serum of controls (elevation about 13-fold, p B0.001) (Fig. 1); with cystatin C being the second highest (pB0.05, elevation about 1.8-fold) (Fig. 3) and cystatin B being the third highest (pB0.001, increase up to 1.4-fold) (Fig. 2). We have shown that in the serum of healthy persons, CA-125 concentration was below 3035 ng/ml (8.491.3 ng/ml), whereas in the ovarian cancer group serum, CA-125 level increased significantly (276.9945.7 ng/ml, p B0.001) as was observed earlier by other authors (1,15). However, CA-125 concentration in ovarian cancer was only about three times higher compared to benign ovarian tumours (77.9952.6, n 9, pB0.05).

Procathepsin B In the control group of practically healthy persons aged 1840 years (14 persons), 4155 years (10 persons) and 5680 years (8 persons), serum procathepsin B concentration did not reveal age dependency (Fig. 1a). A tendency towards a decreased level of serum procathepsin B was observed in the group of elder patients (5680 years) (Fig. 1a). The significantly increased concentration of procathepsain B up to 186.4923.48 ng/ml was revealed in the serum of patients with ovarian cancer, p B0.001 (Fig. 1b), especially in the cases of ascites-producing ovarian tumours. In the ovarian cancer group, both levels of serum procathepsin B and CA-125 significantly increased (both p B0.001) compared to the controls. Significant (p B0.001) elevation in procathepsin B was


Evaluation of serum procathepsin B, cystatin B and cystatin C

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** Cystatin B concentration, ng/mL

Procathepsin B concentration, ng/mL

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Benign Ovarian Ovarian Cancer Tumor (II-IV stage) (n=9)(n=6) (n=14) (n=11) The data are shown as mean±SEM *- p < 0,05; ** - p