Face-to-face interviews conducted by AI community members are an effective means of gathering health information about AIs living in rural, reservation communities. AIs living in these communities on the northern plains have a much higher prevalence of many health-risk behaviors and some medical conditions than are found in the general population. Improved health-care access, better preventive screenings, and culturally appropriate community-based health promotion programs and policies should be examined as possible ways to reduce health disparities.

BACKGROUND Many American Indian and Alaska Native veterans are eligible for healthcare from Veterans Health Administration (VHA) and from Indian Health Service (IHS). These organizations executed a Memorandum of Understanding in 2003 to share resources, but little was known about how they collaborated to deliver healthcare. OBJECTIVE To describe dual use from the stakeholders’ perspectives, including incentives that encourage cross-use, which organization’s primary care is “primary,” and the potential problems and opportunities for care coordination across VHA and IHS. PARTICIPANTS VHA healthcare staff, IHS healthcare staff and American Indian and Alaska Native veterans. APPROACH Focus groups were conducted using a semi-structured guide. A software-assisted text analysis was performed using grounded theory to develop analytic categories. MAIN RESULTS Dual use was driven by variation in institutional resources, leading patients to actively manage health-seeking behaviors and IHS providers to make ad hoc recommendations for veterans to seek care at VHA. IHS was the “primary” primary care for dual users. There was little coordination between VHA and IHS resulting in delays and treatment conflicts, but all stakeholder groups welcomed future collaboration. CONCLUSIONS Fostering closer alignment between VHA and IHS would reduce care fragmentation and improve accountability for patient care.

The objective of the present study was to identify barriers to and facilitators of physical activity among American Indian adults living on a rural, U.S. Northern Plains reservation using the nominal group technique (NGT). NGT is a method of data generation and interpretation that combines aspects of qualitative (free generation of responses) and quantitative (systematic ranking of responses) methodologies. Adults participated in one of two NGT sessions asking about either barriers to (n = 6), or facilitators of (n = 5), being physically active. Participants nominated and ranked 21 barriers and 18 facilitators. Barriers indicated lack of knowledge of how to fit physical activity into a daily schedule, work, caring for family members, and prioritizing sedentary pursuits. Other responses included environmental barriers such as lack of access and transportation to a gym, unsafe walking conditions, and inclement weather. Facilitators to following recommendations included knowledge of health benefits of physical activity and the perception of physical activity as enjoyable, including feeling good when working out. Environmental facilitators included being outdoors walking and biking as well as parks and exercise facilities. Responses provided direction for locally designed community-based programs to promote facilitators and decrease barriers to individual’s engagement in physical activity.

Objective: The Dietary Guidelines for Americans (DGA) promote healthy dietary choices for all Americans aged 2 years and older; however, the majority of Americans do not meet recommendations. The goal of the present study was to identify both barriers and facilitators to adherence to DGA recommendations for consumption of five recommended food groups: grains (specifically whole grains), vegetables, fruits, meat/beans and milk (specifically reduced-fat/non-fat), among American-Indian children. Design: Nominal group technique sessions were conducted to identify and prioritize children's perceived barriers and facilitators to following the DGA, as presented in the 'MyPyramid' consumer education icon. After response generation to a single question about each food group (e.g. 'What sorts of things make it harder (or easier) for kids to follow the MyPyramid recommendation for vegetables?'), children individually ranked their top five most salient responses. Ranked responses are presented verbatim. Setting: A rural Northern Plains American-Indian reservation, USA. Subjects: Sixty-one self-selected fifth-grade children. Results: Core barriers for all food groups studied included personal preference (i.e. 'don't like') and environmental (i.e. 'cost too much'; 'store is too far to get them'; 'grandma don't have'). Core facilitators included suggestions, i.e. 'make a garden and plant vegetables'; 'tell your friends to eat healthy'. Conclusions: Barriers and facilitators are dissimilar for individual food groups, suggesting that dietary interventions should target reduction of barriers and promotion of facilitators specific to individual food groups recommended by the DGA. Keywords American-Indian children Nominal group technique Dietary Guidelines for AmericansBarriers and facilitatorsEstimates of obesity among US children aged 6-11 years range from 14 to 24 %, depending upon racial/ethnic group, with the highest prevalence observed in minority children (1) . Recent estimates of the prevalence of obesity among Northern Plains American-Indian (AI) children is 28 % (2) ; similar to that reported in other studies (3)(4)(5) . The number of obese AI children is increasing despite an apparent levelling off among other racial/ethnic groups in the USA (1,2,6) . Obesity is a major risk factor in the development of chronic diseases such as type 2 diabetes (T2DM) and CVD (7) . The prevalence of T2DM in AI children is one of the highest in the country and continues to increase (8,9) . Recent predictions estimate that, without a reduction in obesity, the prevalence of T2DM in AI/Alaska Native youth will increase by 129 %, from 0·56/1000 youths in 2010 to 1·28/1000 youths in 2050 (10) , and AI/Alaska Native adults have the highest prevalence of T2DM of all racial/ ethnic groups in the USA (11) . Considering that obesity in childhood is likely to persist into adulthood (12) , early prevention may be the only way to decrease the significant individual and societal burden of poor health in AI communities (13)(14)(15)(16) . Excess e...

However, the case mortalities for colorectal and prostate cancers among AI men in the Northern Plains exceed those for US men of all racial/ethnic populations by 59% and 48%, respectively.Recent studies have linked obesity with cancer, including colorectal and prostate cancer. [3][4][5] In the United States, 67% of all adult men and 77% of AI adult men are overweight/obese.6 Obesity is associated with decreased access to care and lower rates of some cancer screening behaviors. 7,8 The influence of obesity on receipt of colorectal cancer screening tests, however, is inconsistent but appears to vary with sex and test type. In 2 available studies on prostate specific antigen (PSA) testing, men with a higher body mass index (BMI) were more likely than their lighter counterparts to have had recent PSA testing. 10,11 Rurality is another barrier to health care access and cancer screening. 12,13 Rural residents are more likely to experience poor health and chronic conditions than their urban counterparts.