The COVID-19 pandemic underscored many strengths of the Alaska Tribal Health System (ATHS) and the Alaska Native Tribal Health Consortium (ANTHC), however it also brought to light opportunities for improvement in Tribal public health infrastructure throughout the state and emphasized the need for ANTHC and the ATHS to be better prepared for future public health emergencies.
Supported by TECPHI funding from the Centers for Disease Control and Prevention, the Alaska Native Epidemiology Center (ANEC) contributed to ANTHC’s efforts to invest purposefully in infrastructure to improve public health and strengthen its capacity. Using Tribal public health assessments, ANEC staff worked throughout FY23 and FY24 to evaluate the ATHS’s capacity to deliver the essential public health services and inform ANTHC’s efforts to align its public health initiatives with its strategic direction.
As a result of the information gained in these assessments, ANTHC identified areas for which an immediate was response was possible including funding additional positions in Emergency Preparedness, establishing Tribal public health infrastructure sub-award funding opportunities, creating a Research Advisory Network, and strengthening partnerships and networking relationships with partners such as the State of Alaska. Additional work continues on these assessments, and the results continue to provide valuable insights for the Alaska Native EpiCenter, the ANTHC Division of Community Health Services, and the organization as a whole.
Maria Caruso presents on Tribal Public Health Assessment processes and results and the 2023 EpiCenter Scientific Advisory Council.
The state’s two largest urban health departments have dedicated public health infrastructure funding to building stronger relationships with area tribal nations.
The Inter Tribal Council of Arizona, Inc. (ITCA) Tribal Epidemiology Center Public Health Infrastructure (TECPHI) Team holds Public Health Working Group (PHWG) Meetings to provide a gathering space for collaboration among Tribal public health programs. Through a strategic planning meeting held in March 2023, the TECPHI Team established 3 main goals for the working group meeting series:
Provide a collaborative public space to enhance relationships,
Promote and improve awareness of Tribal Epidemiology Center services, and
Provide public health/health data training and education at no cost.
To date, the TECPHI Team has hosted 4 PHWG meetings during this 5-year funding cycle, with attendees from Tribal organizations in Arizona, Nevada, and Utah, along with presenters traveling from across the country to provide trainings or present on various public health programs. The TECPHI Team is currently planning the 5th PHWG meeting, which will be held on June 4, 2024 on the topic of Substance Use and Overdose Prevention.
The first PHWG meeting of the series was held virtually. It has since shifted to in-person meetings after receiving feedback that participants preferred an in-person format.
During the course of the 4 PHWG meetings that have been held, the gathering has expanded from a 4-hour virtual meeting to a full-day (or 2-day) in-person meeting. Additionally, due to the success of the first two PHWG meetings held in Year 1, the TECPHI Team has moved forward with offering the meetings every quarter in Year 2. Speakers have included Tribal health program leadership and staff, medical providers, the Arizona Department of Health Services, and our fellow colleagues from other Tribal Epidemiology Centers. These presenters provided information about their programs or gave trainings pertaining to the meeting topics.
Through these presentations and breakout discussions, attendees have been able to share information, opportunities, and resources with each other. Of note, the most recent PHWG meeting on Maternal and Child Health enabled participants to provide invaluable information and recommendations for updates to an Arizona Tribal Maternal and Child Health Needs Assessment that the TECPHI Team is currently working on.
PHWG Meeting attendance has increased from 20 to 43 people (see tables for more information), many of whom have been returning attendees. The most recent working group meeting had so many registrants that the number of attendees had to be limited due to conference room capacity. Meeting participants provide helpful feedback and insight to the TECPHI Team via evaluation surveys after each meeting. The surveys include questions about the format and content of the meetings to improve future gatherings and ensure they are useful to our Tribal public health partners. To date, the TECPHI Team has received 80 survey responses across the 4 meetings, enabling them to integrate participant feedback into their planning and implementation. For example, when asked if the meeting provided a collaborative environment for discussion, 73% of survey respondents strongly agreed, 27% agreed, and 0% were neutral, disagreed, or strongly disagreed.
Additionally, the TECPHI PHWG Meetings series has strengthened the relationships and partnerships between the TECPHI Team and other ITCA Departments, including the Social Media Manager, Assistant Director, Maternal Health Innovation Department, and Health and Human Services Department. The PHWG meetings have also enabled the TECPHI Team to connect with and collaborate with other TECs around the country, including the Northwest Portland Area Indian Health Board, Southern Plains Tribal Health Board, and the Albuquerque Area Southwest Tribal Epidemiology Center.
The TECPHI Team has found that the PHWG meeting series has greatly expanded opportunities for collaboration with our public health partners. Overall, the PHWG meetings have been successful in providing an environment for discussion, collaboration, sharing information, and building relationships between the ITCA TECPHI Team, Tribal health programs, ITCA departments, Tribal Epidemiology Centers, and other public health partners.
All Nations Health Center: Improving Community Health Through a Needs Assessment
The Urban Indian Health Institute was recently able to utilize funding from the Building Resilience and Action to Nurture Community Health (BRANCH) program to support the Sweetgrass Community Grants Program (CGP). The CGP funds cohorts of subgrantees to promote public health infrastructure and capacity building in Urban Indian Organizations throughout the country. All Nations Health Center was recognized for its demonstrated commitment to advancing public health infrastructure for urban Indian populations and was selected as a 2022-2023 Sweetgrass Grant awardee.
All Nations Health Center (All Nations), an urban Indian organization in Missoula, Montana, focuses on providing comprehensive healthcare services and programming for chronic disease prevention and management to promote health and social well-being of its clients. Programming and clinical practices at All Nations draw upon Western medicine, as well as community, cultural, and familial strengths. All Nations also places a strong emphasis on Indigenous knowledge, methods, and remedies as critical components to the health and wellness of its clients.
All Nations conducted a community needs assessment to better understand the needs and health landscape of Missoula’s Indigenous community. All Nations has a rich history of conducting needs assessments to better understand and address the community’s evolving needs, though with recent organizational changes as well as the COVID-19 pandemic, eight years had passed since the last one. BRANCH funding helped support the current needs assessment, which provides valuable insights into the impact of recent organizational changes, assesses the adequacy of existing services, and guides future initiatives in alignment with the community’s dynamic requirements.
The Community Needs Assessment project was facilitated by the All Nations Cultural Epidemiologist and Research Assistant. The process also included a dedicated Community Advisory Board (CAB) whose members each played a pivotal role in decision making. While the assessment ultimately prioritized Indigenous youth ages 16-26, the process recognized and emphasized the interconnectedness between generations in the community. Key informant conversations, focus groups, voting with coffee cans, and a comprehensive survey shaped the research methodology, providing insights into community priorities and challenges. The survey, comprising 106 items, was distributed electronically and on paper, yielding 216 responses. The Sweetgrass Community Grant, made available through BRANCH, funded essential components, including support for CAB meetings, CAB member honoraria, and incentives for focus group and survey participants. Each of these financial supports helped reinforce involvement and investment in the success of the needs assessment.
The highest goal of the assessment was to offer important, realistic, and actionable recommendations for All Nations to implement that follow the aim to build upon existing strengths and address identified gaps, fostering a community-centric approach to well-being.
The project resulted in a report which outlines four important and realistic recommendations to achieve lasting impact on supporting the community’s health needs. All Nations gathered information about existing services, preferred communication channels, interest in potential services, and barriers to attending activities. This information was collected from key informant conversations, focus groups, survey responses, and conversation among the CAB.
Key findings highlighted the prevalent unmet basic needs, with 70% of participants reporting challenges meeting their basic needs over the last 12 months. Survey participants showcased a strong engagement with and high interest in existing services provided by All Nations, with medical care, harvesting/picking, Traditional Ecological Knowledge, Wellness Wednesdays in summer, dental services, and vaccines being most popular. Participants also indicated high interest in several potential services including fitness activities and Native dancing classes, among others. Addressing barriers to service utilization, participants stressed the importance of advanced event awareness and clarity about activity expectations.
After considering this information, All Nations developed nine draft recommendations and the CAB met several times to finalize the recommendations. Considerations made in determining the final recommendations included community priority as identified from the survey, feasibility, All Nations capacity, and alignment with All Nations core values, vision, and mission. The recommendations are listed below:
A. “101” Media Series: Introduce a media series aiming to increase community awareness and understanding of available services, fostering inclusivity and trust.
B. Nations Calendar: Implement a digital calendar on the All Nations website, detailing events one month in advance. Weekly communications via various channels, including email, text, and social media, will keep the community informed about upcoming events, addressing the identified need for improved outreach.
C. Social Services Companionship: Leverage the Community Health Workers program to provide social services companionship. This initiative focuses on guiding community members through resources access processes, improving navigation of services, and ensuring a supportive environment.
D. Multi-purpose Space in New Building: Design and incorporate a versatile multi-purpose space in the new building. This space should accommodate a range of activities, meeting the community’s interests in fitness and cultural classes, among other activities. Features like collapsible walls, storage, and technology should be considered for optimal functionality.
These initiatives aim to improve community awareness and knowledge about existing programming, addressing concerns about expectations at events. Additionally, the social services companionship recommendation leverages the existing Community Health Workers program to provide support and navigation for community members facing difficulties meeting basic needs. The recommendation for a multi-purpose space in the new building aligns with community interests, offering versatile amenities to cater to activities like physical fitness activities and cultural classes. These recommendations collectively address immediate challenges identified through the assessment, providing a strategic framework for All Nations to enhance its services and foster community health and well-being.
This needs assessment showcased the effectiveness of a strong community engagement model. In summary, its findings and recommendations celebrate the community’s engagement with existing services, reveal untapped potential, and provide a comprehensive understanding of preferences and needs.
Established in 2003, the Great Plains Tribal Epidemiology Center (GPTEC) serves the 17 federally recognized tribes and one tribal service unit in North Dakota, South Dakota, Iowa, and Nebraska. The goal of GPTEC is to provide epidemiological services to these tribal communities, including providing public health data and reports to help tribes prioritize health needs.
GPTEC has, however, for years struggled with a lack of access to data that is representative of the tribes it serves. The reason for this is the systemically racist public health authority. Public health authority refers to an agency or governmental body’s legal ability to access health data for use in public health practice. Tribes are public health authorities due to their status as sovereign nations. Tribal epidemiology centers’ public health authority status was established through the Affordable Care Act in 2010. The Problem and Solution Since GPTEC’s founding, gaining access to anything besides publicly available data involved months and sometimes years of relationship building. GPTEC had to engage with different positions within each state Department of Health and Vital Records and build relationships one by one. Then that person hopefully became GPTEC’s champion for data sharing, and if state law allowed, they began to share. Even then, the data shared was often limited. The data might be given as a five-year average instead of counts by year, for example. This data sharing was often tenuous, as staff turnover more than once left GPTEC starting over, building relationships from the ground up again. One state also underwent a complete restructuring, with the new department deciding that the data that had previously been shared could no longer be shared at all.
While this was problematic before 2020, the true urgency of the issue became clear in 2020, when the COVID-19 pandemic started. Without an established data flow, GPTEC was left spending four or more hours per day, every day, manually entering COVID-19 infections and deaths by county for every county (311 total) in the four-state service area using secondary data sources like the Johns Hopkins COVID-19 tracker. This data, however, was not race-specific, so its use was limited. Eventually, the Public Health Emergency declarations opened direct data sharing with most states, but they still suppressed small numbers in some cases, and some states still refused to share race-specific county data, despite tribal and GPTEC public health authority status. Public health systems were more stressed than ever, and tribes were some of the most vulnerable populations, yet they were left with some of the fewest resources. Some states recognized this and started working directly with tribes, providing them with data extracts of positive cases they could use for contact tracing. Other states did not. It was becoming clear that a sustainable data-sharing solution was vital. This was something that had been discussed before but became a topic of serious discussion during a meeting with South Dakota’s State Epidemiologist and other state program leadership in July 2021. The State Epidemiologist agreed that a more defined data-sharing partnership was needed, however, the State Epidemiologist did not have the final say regarding data outside of their positional purview, including sexually transmitted disease data. The need for this agreement was made even clearer as the pandemic started to formally wind down and the Public Health Emergency ended because data sharing abruptly stopped with multiple states.
With tribes and GPTEC barely being able to take a breath, a new epidemic was simmering, especially in South Dakota. Reports of high rates of syphilis and congenital syphilis started coming in and GPTEC was hearing many of the affected persons were American Indian and Alaska Native. This epidemic came with no public health emergencies, however, and little public attention. GPTEC started requesting syphilis data from the state departments of health and was repeatedly denied. Meanwhile, the cases kept growing and growing and it was becoming clear the majority were Native Americans. The states repeatedly refused to give line-level identifiable data that would allow GPTEC or tribes to perform contact tracing or provide treatment. To try to move a Data Sharing Agreement forward, the South Dakota State Epidemiologist and their team met for a full day with the GPTEC team in the summer of 2022 to go over a draft of a Data Sharing Agreement (DSA). The two teams went over the agreement, line by line, discussing and changing the language to ensure the product they produced would have the highest likelihood of moving through both organization’s legal departments as fast as possible. Despite these efforts, the process moved slowly, all while the syphilis epidemic escalated and tribes and GPTEC were still left with no data.
By March 2023, with local resources exhausted, the Great Plains Tribal Leaders’ Health Board, at the request of GPTEC, contacted the Centers for Disease Control and Prevention (CDC) and requested Epidemiologic Assistance (Epi-Aid). To GPTEC’s knowledge, this was the first time a Tribal Epidemiology Center had requested and received an Epi-Aid. For the CDC to be able to do their work, however, they would need identifiable data on syphilis from the states. GPTEC requested that the CDC abide by “no data about us without us”, meaning that if GPTEC didn’t get access to the data, the CDC did not either. By the time the CDC arrived in South Dakota in July 2023, one state had provided full access almost without question. South Dakota provided access within days of the CDC’s arrival but attempted to block access for GPTEC to some identifiable case investigation data. After much discussion, the CDC eventually agreed to back GPTEC and not access any syphilis data unless GPTEC was also given access. GPTEC was ultimately granted access and activities proceeded. A third state sent data late into the first week, and the final state did not send data until October, delaying the Epi-Aid Final Report by two months. While all this went on, the DSA with South Dakota continued to move back and forth between the Department of Health and GPTLHB legal teams.
Finally, on February 15, 2024, the agreement was finalized. The agreement gave GPTEC an unprecedented level of access to South Dakota data. Once activated, it allowed a near real-time feed of all reportable conditions for American Indians and Alaska Natives, and aggregate data on non-native persons. The only thing stopping the proverbial flip of the switch is GPTEC finalizing its infrastructure to ensure the data is housed securely. This DSA is the culmination of years of hard work and will propel GPTEC and the South Dakota tribes forward in their disease surveillance and response efforts and allow decision-makers a better understanding of the health of their communities. GPTEC hopes this win will set the precedent for the signing of similar DSAs in North Dakota, Iowa, and Nebraska.
