Indigenous Healthy Homes & Healthy Communities

Survey results indicated that eighteen Tribes have concerns about radon and other indoor air pollutants, a key challenge for Tribal communities nationally.2 Exposure to environmental chemicals is linked with cardiovascular disease and cancer disparities in Tribal communities³, yet there exists a dearth of research investigating indoor air quality, exposure and health outcomes in Tribal communities. Nationally, indoor radon exposure is associated with more than 21,000 cancer deaths annually because when inhaled it releases a-particles directly into lung tissue and is the second leading cause of lung cancer mortality in the United States.⁴ Radon is inert, odorless, denser than air, and water soluble and the decay product ofuranium.⁵ This carcinogenic gas may enter homes through cracks in the foundation, floors or via drinking water. However, there are inadequately few examples of radon exposure studies using community-engaged research principles to address concerns of Tribal communities.⁶ Radon is a priority for communities in the AASTEC service area because the counties of northern New Mexico are located in an area the US Environmental Protection Agency considers high risk or moderate risk for indoor residential radon exposure to exceed the action level of4 pCi/L. In 2017 AASTEC began working with two Tribal communities (C-1, C-2 in Table 1) to characterize residential radon exposure with financial support from US Centers for Disease Control and Prevention (6 NU380T000268-02-01), the Indian Health Service Epidemiology Program for American Indian/Alaska Native (Al/AN) and Urban Indian Communities (UlBlIHS000l-21-02), and a pilot project award from the University of New Mexico Center for Native Environmental Health Equity Research (1P50ES026102 & USEPA #83615701) to work with community C-3. The THHP team (including Dr. Hoover) trained 20 tribal staff members from the Tribal government to assess seasonal residential indoor radon concentrations. These community led projects included partnerships with tribal staff and the Indian Health Service Division of Environmental Health, multiple Tribal health boards, environmental services departments, one housing authority and housing board and community health workers. Critically, THHP applied community based participatory research principles and facilitated a process by which tribal communities developed their own assessment programs. Through this work 322 homes were tested for radon using Air Check short-term test kits and results indicated a strong need for radon assessment and mitigation. In community C-3 for example, 42% of tested homes exceeded the radon action level of4.0 pCi/L (Table 1). Sustainability of the program beyond the initial funding was considered from initiation, supported by our strengths-based approach. For example, community partners led the development of radon brochures and information materials that are still distributed at housing fairs and community events. Through established and maintained relationships AASTEC THHP staff are available for additional testing and consultation as needed, including attending housing fairs to discuss radon. Additionally, we prioritized returning all project data to Tribal partners (congruent with Indigenous Data Sovereignty Principles). These data were used by THHP partner communities to secure funds for home remediation and minor home repairs and maintenance.

In 2021 the Albuquerque Area Indian Health Board identified injury prevention (IP) as one of its top five health priorities reflecting the burden experienced by the Al/AN population in our area. In New Mexico, the mortality rate from unintended injuries (121.1 per 100,000 people) among Al/AN residents (2011-2021) was nearly double the rate for any other race/ethnicities in the state. Similarly, the fall-related hospitalization rate (2015-2017) among Al/AN Adults 65+ Years of the state.⁷ Similarly, the fall-related hospitalization rate (2015-2017) among Al/AN Adults 65+ Years of Age (141 per 100,000 people) was more than 2 times the rate for Black/African American and 1.27 times the rate for Hispanics.⁸ To address the critical need for sustained, comprehensive injury prevention programming AAIHB & AASTEC developed and implemented the Tribal Injury Prevention Program (TIPP, IHS D261IHS0155-02-01 & D261IHS0195-01-00). TIPP, AASTEC staff, and partners conduct training for home fall risk assessments, provide home modification adaptive or assistive devices and have developed the AASTEC Injury Atlas to better understand the burden of falls and other injuries among the AI/AN population of New Mexico. TIPP staff conduct a bi-annual (started in 2016) regional tribal injury prevention mixed-method gap analysis and needs assessment, which receives input from an average of 110 IP specialists from the area. TIPP has established a regional multi-sector tribal IP coalition (averaging 32 coalition participants during quarterly meetings) to impart current subject matter experts with a collaborative, multi-sector approach to injury prevention.

Over the past 8 years, TIPP and AASTEC staff implemented a fall prevention training program that weaves evidence-based best strategies with capacity enhancement initiatives to prevent falls. This includes adapting the CDC's STEAD! toolkit for use in Tribal communities - providing a standardized and culturally congruent training and assessment tool - and as instructors/coaches for the A Matter of Balance (AMOB), Tai Chi for Arthritis and Fall Prevention (TCA) programs. Since 2015 TIPP has facilitated/trained 414 tribal or tribal serving individuals from all 27 Tribal communities in the area; and provided/installed 218 grab bars, 280 night lights, and 150 adjustable hand grip strengtheners for older adults in 110 homes in three communities. Additionally, TIPP Coordinator Dominguez, and AASTEC staff, and partners, conduct home hazard assessments, modifications, and corrections to further address the elevated unintentional injury and mortality rates in communities across the IHS Albuquerque Area; since the onset of the COVID-19 pandemic virtual Technical Assistance has commenced. Similarly, THHP-trained community members (Section B.1) assessed 322 households for fall and injury risk (Table 1), and completed 142 home modifications (e.g., repairing steps; installing smoke alarms; and more). Combined with culturally informed adaptations of the STEADI toolkit, community training activities and certifications, and minor home repairs, AASTEC and its partners work to minimize fall-related injuries. While THHP and TIPP have demonstrated success, a need remains to address structural inequities that contribute to persistent housing, environmental exposure, and fall-risk disparities in Tribal communities.

A growing body of literature supports evidence that long-term exposure to environmental contamination can be psychologically stressful.9 In addition, there is increasing recognition that unequal distribution of resources is a critical component of individual health. Therefore, living in poverty, having impaired quality housing (documented by THHP, section B.2), difficulty accessing high quality health care, lost employment, and other social determinants of health can significantly affect behavioral risk factors, physical and mental stress, and physical health outcomes.10 Therefore, our community-focused intervention will include information collected about personal stressful events, incorporate stress measures as biological response to experienced stressors (using non-invasive saliva collection to promote participation) and examine discrimination experienced in Tribal communities. The Everyday Stressors survey is currently incorporated into assessments at several levels in New Mexico. These include clinical applications at UNM Health Sciences Center clinics (both primary care as well as opioid addiction prevention & service maternity clinics) and in the W.K. Kellogg Foundation-sponsored Tribal PRAMS (Section E.I) program led by AASTEC with 22 New Mexico Tribes, Nations and Pueblos. The Everyday Discrimination Items (EDI) survey will be used to measure chronic experiences of unfair treatment. The instrument captures the frequency of nine experiences in day-to-day lives of respondents, including being treated with: less courtesy than others; less respect than others; receiving poorer service than others; people acting as if you are not smart; acting as if they are afraid of you; acting as if you are dishonest; acting as if they are better than you; being called names or insulted; being threatened or harassed. The validity of this survey is high and has previous application with Tribal communities (Cronbach’s alpha coefficients range from 0.80 to 0.88 and high internal reliability (a = 0.92) for a study with 3,039 Al/AN participants).¹¹

Respiratory health remains a key challenge to address among Indigenous communities in the AASTEC service area due to environmental exposures particular to Tribal communities, documented need to improve housing conditions (a far-reaching need among Tribal and rural communities across the United States), and disparate access to specialty services necessary to diagnose and manage respiratory diseases. Asthma is one of the most common lung conditions in adulthood, estimated to affect 8% of the US population.¹² According to the New Mexico Department of Health 1 in 13 New Mexicans (8.4% of adults and 5.4% children) suffer from asthma, and more than half are uncontrolled.13 In stark comparison, results from the THHP indicated that 18-29% of Tribal homes reported adult residents with asthma (Table 1). While not directly comparable, the THHP data supports community requests to address asthma concerns, congruent with AASTEC's health priority areas established in cooperation with our Executive Council. Unfortunately, asthma causes significant morbidity and mortality due to lack of recognition, undertreatment, and failure of environmental modification. This inflammatory disease of the lungs is driven by indoor environmental exposures including mold, insects (cockroach, dust mite), animal dander, environmental tobacco smoke (ETS), indoor wood smoke, and dust.^{14 15 16} THHP data suggest high rates of mold and wood smoke exposure in the Tribal communities (Table 1); the burden or prevalence of other allergens in these communities is not known. Critically, fewer than one-third of adult asthma patients in NM report that home remediation was recommended by their provider.13 In addition, THHP (Table 1) and AASTEC data¹⁷ show high rates of Tribal ETS exposure and cigarette use. Additionally, 66% of Al/AN adults in NM who smoke reported at least one attempt to quit in the last 12 months; research by Dr. Erdei and a Tribal community documented that on average, people attempted to quit 6 times.¹⁸ High prevalence of a fast metabolizing CYP2A6 enzyme variant in tribal communities likely contributes to cessation challenges.¹⁹ However, while most individuals who smoke would like more local service smoking cessation services,¹⁷ current federal support with IHS and NM Department of Health only provide 30 days of smoking cessation products, which is clearly insufficient for sustained cessation and reduction of ETS.¹⁸ Therefore, community-level structural change for smoking cessation is a critical unmet need for improving indoor air quality and community health in the short and long term. Further, reduction of disease burden requires standard medical therapy.^{14 15} Based on our experiences working with IHS and Tribal (Public Law 93-638 (P.L. 638)) facilities in the region, we observed a lack of access to asthma management specialty services, compounded by clinic understaffing. There is a vital need to disseminate training and support for primary care providers locally and pathways for patient asthma education, treatment referrals, and referrals for resources that support commercial tobacco smoking cessation, with environmental remediation.