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Objectives: To determine differences among multi-race (MR) American Indian and Alaska Natives (AIAN), single race (SR) AIANs, and SR-Whites on multiple health outcomes. We tested the following hypotheses: MR-AIANs will have worse health outcomes than SR-AIANs; SR-AIANs will have worse health outcomes than SR-Whites; MR-AIANs will have worse health outcomes than SR-Whites. Methods: Behavioral Risk Factor Surveillance System data were used to examine general health, risk behaviors, access to health care, and diagnosed chronic health conditions. Those identifying as SR-White, SR-AIAN, and MR-AIAN were included in multinomial logistic regression models. Results: Compared to SR-AIANs, MR-AIANs had more activity limitations, a greater likelihood of experiencing cost as a barrier to health care and were more likely to be at increased risk and diagnosed with more chronic health conditions. Both SR and MR-AIANs have worse health than SR-Whites; MR-AIANs appear to be at increased risk for poor health. Conclusions: The current study examined access to health care and nine chronic health conditions, neither of which have been considered in prior work. MR AIANs are at increased risk compared to SR groups. These observations beg for further inquire into the mechanisms underlying these differences including stress related to identify, access to care, and discrimination. Findings support the continued need to address health disparities among AIANs regardless of SR or MR identification. [ABSTRACT FROM AUTHOR]

Objective: This study evaluated whether regression from impaired glucose regulation (IGR) to normal glucose regulation (NGR) after 1 year of a lifestyle intervention reduces diabetes risk in American Indians and Alaska Natives (AI/ANs). In addition, we sought to identify predictors for regression to NGR and understand possible mechanisms for the association between NGR and future diabetes risk.Research Design and Methods: Data from participants enrolled from 2006 to 2009 in the Special Diabetes Program for Indians Diabetes Prevention Program with IGR at baseline and an oral glucose tolerance test at year 1 were analyzed (N = 1,443). Cox regression models were used to estimate the subsequent diabetes risk (year 1 to year 3) by year 1 glucose status. Mediation analysis was used to estimate the proportions of the association between year 1 glycemic status and diabetes risk explained by specific factors.Results: Those who reverted to NGR at year 1 (38%) had lower diabetes risk than those with sustained IGR (adjusted hazard ratio 0.28, 95% CI 0.12-0.67). The lower risk associated with regression to NGR was explained by both baseline risk factors and differences in weight loss. Metformin use, weight loss, and an increase in exercise were modifiable risk factors associated with higher odds of regression to NGR.Conclusions: Patients with prediabetes who reverted to NGR had a reduced risk of developing type 2 diabetes over the next 2 years. Both baseline and modifiable risk factors explained the risk reduction associated with NGR. [ABSTRACT FROM AUTHOR]

Purpose: To examine the prevalence of common psychiatric disorders and associated treatment-seeking, stratified by gender, among American Indians/Alaska Natives and non-Hispanic whites in the United States. Lifetime and 12-month rates are estimated, both unadjusted and adjusted for sociodemographic correlates.Method: Analyses were conducted with the American Indians/Alaska Native (n = 701) and Non-Hispanic white (n = 24,507) samples in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions [(NESARC) n = 43,093].Results: Overall, 70 % of the American Indian/Alaska Native men and 63 % of the women met criteria for at least one Diagnostic and Statistical Manual-IV lifetime disorder, compared to 62 and 53 % of Non-Hispanic white men and women, respectively. Adjusting for sociodemographic correlates attenuated the differences found. Nearly half of American Indians/Alaska Natives had a psychiatric disorder in the previous year; again, sociodemographic adjustments explained some of the differences found. Overall, the comparisons to non-Hispanic whites showed differences were more common among American Indian/Alaska Native women than men. Among those with a disorder, American Indian/Alaska Native women had greater odds of treatment-seeking for 12-month anxiety disorders.Conclusion: As the first study to provide national estimates, by gender, of the prevalence and treatment of a broad range of psychiatric disorders among American Indians/Alaska Natives, a pattern of higher prevalence of psychiatric disorder was found relative to Non-Hispanic whites. Such differences were more common among women than men. Prevalence may be overestimated due to cultural limitations in measurement. Unmeasured risk factors, some specific to American Indians/Alaska Natives, may also partially explain these results. [ABSTRACT FROM AUTHOR]

Objective: To investigate possible socioeconomic disparities in weight and behavioral outcomes among American Indian and Alaska Native (AI/AN) participants in a translational diabetes prevention project.Research Design and Methods: We analyzed data from the Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) Program, an evidence-based lifestyle intervention to prevent diabetes in 36 AI/AN grantee sites. A total of 2,553 participants started the 16-session Lifestyle Balance Curriculum between 1 January 2006 and 31 July 2008. Linear mixed models were used to evaluate the relationships of participant and staff socioeconomic characteristics with weight and behavioral outcomes at the end of the curriculum.Results: A strong, graded association existed between lower household income and less BMI reduction, which remained significant after adjusting for other socioeconomic characteristics. Compared with others, participants with annual income <$15,000 also had less improvement in physical activity and unhealthy food consumption in bivariate models, but the relationships were only marginally significant in multivariate regressions. Furthermore, grantee sites with fewer professionally prepared staff were less successful at improving participant BMI and healthy food consumption than the other sites. The strong association between income and BMI reduction was reduced by 20-30% in the models with changes in diet variables but was unrelated to changes in physical activity.Conclusions: Significant socioeconomic disparities exist in weight outcomes of lifestyle intervention at both participant and site staff levels. Helping low-income participants choose more affordable healthy foods and increasing the proportion of professionally trained staff might be practical ways to maximize the effectiveness of lifestyle interventions implemented in "real-world" settings. [ABSTRACT FROM AUTHOR]

OBJECTIVE--The landmark Diabetes Prevention Program (DPP) showed that lifestyle intervention can prevent or delay the onset of diabetes for those at risk. We evaluated a translational implementation of this intervention in a diverse set of American Indian and Alaska Native (AI/ AN) communities. RESEARCH DESIGN AND METHODS--The Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) demonstration project implemented the DPP lifestyle intervention among 36 health care programs serving 80 tribes. A total of 2,553 participants with prediabetes were recruited and started intervention by 31 July 2008. They were offered the 16-session Lifestyle Balance Curriculum and underwent a thorough clinical assessment for evaluation of their diabetes status and risk at baseline, soon after completing the curriculum (postcurriculum), and annually for up to 3 years. Diabetes incidence was estimated. Weight loss, changes in blood pressure and lipid levels, and lifestyle changes after intervention were also evaluated. RESULTS--The completion rates of SDPI-DP were 74, 59, 42, and 33% for the postcurriculum and year 1, 2, and 3 assessments, respectively. The crude incidence of diabetes among SDPI-DP participants was 4.0% per year. Significant improvements in weight, blood pressure, and lipid levels were observed immediately after the intervention and annually thereafter for 3 years. Class attendance strongly correlated with diabetes incidence rate, weight loss, and change in systolic blood pressure. CONCLUSIONS--Our findings demonstrate the feasibility and potential of translating the lifestyle intervention in diverse AI/AN communities. They have important implications for future dissemination and institutionalization of the intervention throughout the Native American health system. [ABSTRACT FROM AUTHOR]

The Everyday Discrimination Scale (EDS) has been used widely as a measure of subjective experiences of discrimination. The usefulness of this measure for assessments of perceived experiences of discrimination by American Indian and Alaska Native (AI/AN) peoples has not been explored. Data derived from the Special Diabetes Program for Indians--Healthy Heart Demonstration Project (SDPI-HH), a large-scale initiative to reduce cardiovascular risk among AI/ANs with Type 2 diabetes. Participants (N = 3,039) completed a self-report survey that included the EDS and measures of convergent and divergent validity. Missing data were estimated by multiple imputation techniques. Reliability estimates for the EDS were calculated, yielding a single factor with high internal consistency (α = .92). Younger, more educated respondents reported greater perceived discrimination; retired or widowed respondents reported less. Convergent validity was evidenced by levels of distress, anger, and hostility, which increased as the level of perceived discrimination increased (all p < .001). Divergent validity was evidenced by the absence of an association between EDS and resilient coping. Resilient coping and insulin-specific diabetes knowledge were not significantly associated with perceived discrimination (p = .61 and 0.16, respectively). However, general diabetes-related health knowledge was significantly associated with perceived discrimination (p = .02). The EDS is a promising measure for assessing perceived experiences of discrimination among those AI/ANs who participated in the SDPI-HH. [ABSTRACT FROM AUTHOR]

The health service ecology varies considerably across urban-rural divides for American Indian and Alaska Native (AIAN) veterans, which may place rural AIAN veterans at high risk for poor health outcomes. Using the Behavioral Risk Factor Surveillance System 2011 and 2012 data for its detailed race information, we employed adjusted multinomial logistical regression analyses to estimate differences in health outcomes among rural AIAN veterans (n = 1500) and urban AIAN veterans (n = 1567). We used rural White (n = 32,316) and urban White (n = 59,849) veteran samples as comparators. No statistically significant differences between urban and rural AIAN veterans' health outcomes were found. Urban AIAN veterans were 72% more likely to report financial barriers to care compared with urban White veterans (P = .002); no other healthcare access differences were found. Compared with their White veteran counterparts, both urban and rural AIAN veterans were significantly more likely to report poorer physical and mental health across an array of outcomes. Overall, rural and urban AIAN veterans' health outcomes were similar, but both groups suffered compromised health compared with that of both rural and urban White veterans. The findings identified key areas for improving and innovating care for both rural and urban AIAN veterans.

Using multilevel analysis, this study investigated participant and site characteristics associated with participant retention in a multisite diabetes prevention translational project among American Indian and Alaska Native (AI/AN) people. We analyzed data from the Special Diabetes Program for Indians Diabetes Prevention Program (SDPI-DP), a lifestyle intervention to prevent diabetes implemented in 36 AI/AN grantee sites. A total of 2,553 participants were recruited and started the intervention between January 1, 2006 and July 31, 2008. They were offered the 16-session Lifestyle Balance Curriculum from the Diabetes Prevention Program (DPP) in the first 16-24 weeks of intervention. Generalized estimating equation models and proportional hazards models with robust standard error estimates were used to evaluate the relationships of participant and site characteristics with retention. As of July 31, 2009, about 50 % of SDPI-DP participants were lost to follow-up. Those who were younger, male, with lower household income, no family support person, and more baseline chronic pain were at higher risk for both short-term and long-term retention failure (i.e., not completing all 16 DPP sessions and loss to follow-up, respectively). Sites with large user populations and younger staff had lower likelihood of retaining participants successfully. Other site characteristics related to higher risk for retention failure included staff rating of participant disinterest in SDPI-DP and barriers to participant transportation and child/elder care. Future translational initiatives need to pay attention to both participant- and site-level factors in order to maximize participant retention.

Objective: The landmark Diabetes Prevention Program (DPP) showed that lifestyle intervention can prevent or delay the onset of diabetes for those at risk. We evaluated a translational implementation of this intervention in a diverse set of American Indian and Alaska Native (AI/AN) communities., Research Design and Methods: The Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) demonstration project implemented the DPP lifestyle intervention among 36 health care programs serving 80 tribes. A total of 2,553 participants with prediabetes were recruited and started intervention by 31 July 2008. They were offered the 16-session Lifestyle Balance Curriculum and underwent a thorough clinical assessment for evaluation of their diabetes status and risk at baseline, soon after completing the curriculum (postcurriculum), and annually for up to 3 years. Diabetes incidence was estimated. Weight loss, changes in blood pressure and lipid levels, and lifestyle changes after intervention were also evaluated., Results: The completion rates of SDPI-DP were 74, 59, 42, and 33% for the postcurriculum and year 1, 2, and 3 assessments, respectively. The crude incidence of diabetes among SDPI-DP participants was 4.0% per year. Significant improvements in weight, blood pressure, and lipid levels were observed immediately after the intervention and annually thereafter for 3 years. Class attendance strongly correlated with diabetes incidence rate, weight loss, and change in systolic blood pressure., Conclusions: Our findings demonstrate the feasibility and potential of translating the lifestyle intervention in diverse AI/AN communities. They have important implications for future dissemination and institutionalization of the intervention throughout the Native American health system.

The National Heart, Lung, and Blood Institute developed the Honoring the Gift of Heart Health (HGHH) curriculum to promote cardiovascular knowledge and heart-healthy lifestyles among American Indians and Alaska Natives (AI/ANs). Using data from a small randomized trial designed to reduce diabetes and cardiovascular disease (CVD) risk among overweight/obese AI/ANs, we evaluated the impact of an adapted HGHH curriculum on cardiovascular knowledge. We also assessed whether the curriculum was effective across levels of health literacy (defined as the 'capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions'). We examined change in knowledge from baseline to 3 months for two groups: HGHH (N = 89) and control (N = 50). Compared with controls, HGHH participants showed significant improvement in heart attack knowledge and marginally significant improvement in stroke and general CVD knowledge. HGHH participants attending ≥1 class showed significantly greater improvement than controls on all three measures. Although HGHH participants with inadequate health literacy had worse heart attack and stroke knowledge at baseline and 3 months than did participants with adequate skills, the degree of improvement in knowledge did not differ by health literacy level. HGHH appears to improve cardiovascular knowledge among AI/ANs across health literacy levels.

Background: Because of their broad geographic distribution, diverse ownership and operation, and funding instability, it is a challenge to develop a framework for studying substance abuse treatment programs serving American Indian and Alaska Native communities at a national level. This is further complicated by the historic reluctance of American Indian and Alaska Native communities to participate in research., Objectives and Methods: We developed a framework for studying these substance abuse treatment programs (n ≈ 293) at a national level as part of a study of attitudes toward, and use of, evidence-based treatments among substance abuse treatment programs serving AI/AN communities with the goal of assuring participation of a broad array of programs and the communities that they serve., Results: Because of the complexities of identifying specific substance abuse treatment programs, the sampling framework divides these programs into strata based on the American Indian and Alaska Native communities that they serve: (1) the 20 largest tribes (by population); (2) urban AI/AN clinics; (3) Alaska Native Health Corporations; (4) other Tribes; and (5) other regional programs unaffiliated with a specific AI/AN community. In addition, the recruitment framework was designed to be sensitive to likely concerns about participating in research., Conclusion and Scientific Significance: This systematic approach for studying substance abuse and other clinical programs serving AI/AN communities assures the participation of diverse AI/AN programs and communities and may be useful in designing similar national studies.

Objective: Research suggests that health literacy (HL) is associated with clinical outcomes. Few studies, however, have examined the mechanisms accounting for this relationship. To understand why HL is related to outcomes, we tested a theoretical framework proposing that diabetes-related knowledge and behavior mediate (explain) the relationship between HL and glycemic control (i.e., A1c)., Methods: Analyses used baseline data from the Special Diabetes Program for Indians Healthy Heart Project (N=2594), an intervention to reduce cardiovascular risk among American Indians/Alaska Natives (AI/ANs) with diabetes. Three nested structural equation models tested the theoretical framework., Results: Model 1 demonstrated that participants with stronger HL skills had better glycemic control. Model 2 tested whether diabetes-related behaviors accounted for this relationship. Self-monitoring of blood glucose significantly mediated the HL-A1c relationship. Model 3 examined the role of diabetes knowledge, showing that it mediated the relationship between HL and dietary behavior. When knowledge was included, behavior was no longer a significant mediator, suggesting that knowledge was the main driver of the relationship between HL with A1c., Conclusion: Interventions to improve knowledge may be particularly important in enhancing outcomes among AI/ANs with diabetes., Practice Implications: Strategies known to enhance patient comprehension may enable low-literate patients to develop needed diabetes knowledge., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objectives: This study evaluated the quality of diabetes care for older American Indians and Alaska Natives., Methods: We analyzed the Indian Health Service Diabetes Care and Outcomes Audit to determine whether completion of indicators of diabetes care differed as a function of age and whether additional patient and program factors were also associated with completion of the majority of the indicators., Results: Completion rates varied by age group, with significantly lower rates seen among the youngest and oldest. Patient diabetes education and duration of diabetes were most strongly associated with the completion of the majority of these indicators., Conclusions: Further studies are needed to determine effective interventions, including diabetes education, to improve the quality of diabetes care in the youngest and oldest age groups.